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ORIGINAL 4 .co SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION P Telephone:(209) 468-3147 Fax: (209)468-3433 Web:www.sfoov-otnleh UNIT IV WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. 540 South Center St E Church St Stockton,CA 95203 t�(y ^f Site Location Cross Street City/State Zip APN l l`0 !D^01 Property PGE 3301 Industrial Ave (916) 408-3314 Owner Address citylStale Rocklin, 95203Phone C-57 Contractor VironeR Address 1641 Challenge Dr. City/State cDn,. giic 705927 Phone 995-R49-6970 Consultant/Sub Cntr Haley Sr A1rlriclAddress 2033 North Main CitylState Walnut Cg@ek,CA phone 925-949-1016 Billable Party Haley&Aldrich Address 2033 North Main CitylState Walnut Wz k,CA 94PR&ar,�gRy 5. 94 GIS Coordinates:X Y RECE' D CONSTRUCTION WORK TO BE PERFORMED: APR r� Pq NEW WELLIBORING(CPT.GEOPRODE,HYDROPUNC�H,Hyy rqyG R.OTHER) " '�R ID SOIL BORING IDs S?S tlAfJfnyl� S 6^l SAu 3 2015 ❑WELL IDs r E]OTHER IDs LrH hT TYPE&If OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS EA? _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE „ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA' _O EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS _TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE 14 SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes)Q No(MAXIMUM F EE FALL DEPTH IS 30 FT) —❑INJECTION f e An Beanie,Omnel�HAND AUGER ,L$_GROUT SPECIFICATIONS r 'r /nl.�I0" E]OTHER: ❑OTHER: APPROX.BORING DEPTH ->-0 7"f ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth:_ Bodng DIa: COMMENTS: NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:1CHECKALL THATAPPLYI #OFWELL(S)TOBE DESTROYED ❑OVER-BORE DIAMETER OF NCHES TO DEPTH OF FT W—ELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM Tn Fr BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS El HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS 6 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 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 Regulations gplicable California laws. Signed Title/CompanySLAWR FRUEST A40, HALEY h pp MJ121r/I Print Name j 1AA Date12-.p I5 DEPARTMENIT_USE ONLY 1 SITE MAP IN UNIT IV FILE-SITE ADDRESS !'PJ�(LS • ,'O.N+U S >-ClI" J'TD(M^F:7f WORK PLAN DATED O APPLICATION ACCEPTED BY rl` P-Iy DAT SS ED / AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE '� 7 DESTRUCTION INSPECTION BY DATE COM MENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED C # RECV'D BY DATE SERVICE PRO: RO# REQUEST R# INVOICE cy 'L -y- Za b $130X 3 � � I �fSJ z3 sR# RO 7600 PR# z900 C-57WC ✓ WAIVER WA- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC�y EHD 29-01 724/14 WELL PERMIT APP