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1 ?`' In••c • SAN JOAQUIN COUNTY '0 FILE COP Y <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> < 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> r Telephone:(209) 468-3147 Fax:(209)468-3433 Web:www.sfgov.ota/eh UNIT IV <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 /> 540 South Center St E Church St Stockton, CA 95203 L,�S r <br /> Site Location Cross Street City/State Zip APN �A �-070"'01 <br /> Property PGE - 3301 Industrial Ave 'A (916)408-3314 <br /> Owner Address City/Stale IZOCklIII,�kqr 95203 Phone <br /> C-57 Contractor Vironex Address 1641 Challenge Dr. City/State (-nnrprdic 705927 Phone 975-949-6970 <br /> Consultant/Sub Cntr Haley 9' AldrLcjjMdress 2033 North Main city/Slate Walnut C(rgek,CA Phone 925-949-1016 <br /> Billable Party Haley&Aldrich Address 2033 North Main City/State Walnut CzFek,CA 94PRA <br /> GIS Coordinates:X Y <br /> RECENFO <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT.SEOrPROBJGU ,HSb' ,OTHER) ayR,- <br /> 2UUI <br /> JI0 SOIL BORING IDs Sou <br /> ❑WELL to <br /> ❑OTHER IDs r" 17+nti7 _ <br /> TYPE§#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2 „ El MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS _TYPE OF CASING:-0 STEEL O PVC 0 OTHER <br /> _O SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS 0 HOSE 0 PIPE <br /> 1 Sl SOIL BORING 91 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yea))No(M=EE FALL DEPTH IS 30 FT) <br /> _0 INJECTION n a NrSoame.Ozmel''X HAND AUGER 1$—GROUT SPECIFICATIONS n(701•F /^C..�1C�h��l. <br /> _0 OTHER: 0 OTHER: APPROX.BORING DEPTH 7-.O 'P+ 0 BOLTED TRAFFIC BOX OR []STOVEPIPE <br /> CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth:_ Boring Dla:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS L BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> _#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDS: ❑PRESSURE GROUT To DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVESFROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS Lj HOSE ❑PIPE ❑MUSHROOM CAP AT L>3 FT) FT BELOW SURFACE <br /> COMMENTS <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 gplicable California laws. <br /> Signed TineroDmpanySCNIoR t'(ld(ncT ,�1AAA6ER, Nhl.e.Y ,(t.J,2)r/l <br /> Print Name f IM Dateghn L2,6 15 <br /> DEPARTMENT USE ONLY 1 t <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS E2ya r . ,0,M r S f e ,S-brr.�C-F:1r <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# - <br /> PECODES FEEINFO AMT REMITTED C E01<C# RECV'D BY DATE SERVICE RO# INVOICE <br /> 2 REQUEST PR# <br /> 2-1a 6!!E 9130, -4 � 0 0!q 4q SJ-/- 4 Z3/� SR# <br /> RO# <br /> 3500 <br /> PR# <br /> (2900) <br /> C-57�_ WC ✓ WAIVER 1&4- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT V— ENCROACHMENT DOCS_ <br /> EHD 29-01 724/14 WELL PERMIT APP <br />