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0.PquIN• • <br /> SAN JOAQUIN COUNTY Dy <br /> ENVIRONMENTAL HEALTH DEPARTMENTLLM <br /> 1868 Hazelton Avenue, Stockton, ww <br /> CA 95205-6232 � ' LOP <br /> i13epH�p Telephone: (209) 468-3147 Fax:(209) 468-3433 Web: SITE MITIGATION <br /> wsig_ ov`o/ehd UN <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 555 Carnegie Steet Mellon Avenue <br /> Property Cross Street Manteca <br /> Owner Wildcat Metals-Carne le LL city/state Zip 95337 APN 221-190 64 <br /> g Address 890 'fate <br /> Court San Jose, CA 95112 �— <br /> c-57 contractor Advanced GeoEnv. 837 Shaw Road City/State <br /> Address Zips phone (408) 912-2287 <br /> consultant/sub torr Advanced GeoEn 837 haw oa cityistate Stockton L1c 680227 209209-46 <br /> Billable Party Advanced G Xddress City/State Stockton 680227 Phone— <br /> Address 837 Shaw Road LI0 Phone 209 467-1006 <br /> GIS Coordinates:X 37.7 Y City/State toctoE 95215 �� <br /> 121583 Zip Phone 209-467-1006 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> 11 NEW WELL/BORING(CPT,GEOPR <br /> ❑SOIL BORING IDs OBE,HYOROPUNCH,HAND-AUGER,OTHER) <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALL_ q_ 'nPE CONSTRUCTION SPECIFICATIONS <br /> _,❑MONITORING ❑HOLLOW STEM <br /> _O EXTRACTION:Vapor/Water DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> ❑HAMMER/DRIVEN CASING THICKNESS <br /> —O SOIL VAPOR PROBE 0 MUD ROTARY TYPE OF CASING: ❑STEEL CI PVC ❑ OTHER <br /> —0 SOIL BORING DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: <br /> ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 yes ❑AUGERS ❑HOSE ❑PIPE <br /> _O INJECTION Ii.,.Air spame, 0 HAND AUGER ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 OTHER: GROUT SPECIFICATIONS <br /> ❑OTHER: APPROX.BORING DEPTH <br /> -❑BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> COMMENTS: _ CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth:P _ Boring Dia: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: <br /> �{VI,4Sgg� p ROY�4' DESTRUCTION M11 E11 THODii: CHECK ALL THAT APPLY <br /> WELL IDs'�"�'V�I�rMVV-1 any MVV-3 ❑OVER-BORE DIAMETER of <br /> GROUT SPECIFICATIONS Portland ®PRESSURE GROUT To DEPTH EF $jCHES TO DEPTH OF FT <br /> TREMIE TYPE TO BEE Ug ED-❑q G RS iJ}{O$ PIPE ❑E7CPLOSIVES FROM r�FT BELOW SURFACE <br /> COMMENTS See at[aCli ed wor�C sFfieet of Wel�and depths ®MUSHROOM CAP Ar > FT BELOW SURFACE <br /> (_3 FT)=—�BELOW SURFACE <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and pplicable ifornla laws, <br /> Signed Title/Com an Geologist/AGE <br /> Print Name William Little p y <br /> Date 03 06/13 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNITIVFILE-SITEADDRESS_ ,SSti 0s91 7f— S'-r rYlypv�?,,.' MAR 0€ 2013 <br /> WORK PLAN DATED 10 r, o%:� <br /> APPL/CAT/ONACCE =D BY <br /> GROUT INSPECTION BY DATE I <br /> DESTRUCTION INSPECTION BY <br /> FINAL INSPECTION BY 6n.r T <br /> Ur <br /> COMMENTS/CONDITIONS: DATE 3-t0�•/ - - J <br /> ACCOUNTING ONLY: AID <br /> PE CODESFAC <br /> FEE INFO #AMT REMITTED CHECK # <br /> RECV'D BY DATE SERVICE RO# <br /> 90 <br /> $125x 3REQUEST PR# INVOICE <br /> �go3 34 7 610UIvr l 3- r3 SR# LeG�GP, <br /> 3�S RO# <br /> 3500 <br /> PR# <br /> C-57y WC ✓ WAIVER (2900) <br /> EHD 29-01 5/09/12 ---LIQ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC <br /> WELL PERMI PP <br />