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SAN JOAQUIN COUNTY ORIGINAL <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> I..k6a an 111 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> •.- P Telephone:-(209) 468-3147 Fax: (209) 468-3433 Web:wwW-sigov-orVeh <br /> gtIFO_ �;. <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 /> 1717 �. Center <br /> Site Location Stree Cross Street W. 3rd Street City Stockton Zip g5206 APN165"072"'28 <br /> PropertyCity of Stockton Address 22 E. Weber Ave. City Stockton Zip 95206 Phone 209-937-8366 <br /> Owner C 7-48516 <br /> I C-57 Contractor Gre Drill' Address City Martinez LT hone .925-313-5$40 <br /> Consultant/SupbGCnntr neer nu Address 210 W. Sand Ba .City Columbia L"ic 62-2-36 Phone — — <br /> Billable Party Afi�IersO u1 Address 210 W Sand Bank Rd.City-Cr)3_i1mhi a _Zips?-4 Phone 618-281-13 <br /> GIS Coordinates:X 37.935 . Y-121.286 _ <br /> CONSTRUCTION WORK TO BE PERFORMED:. <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDS <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE 8,#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING [:3 HOLLOW STEM DIA.Of BOREHOLE ❑MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA: <br /> —❑EXTRACTION:Vapor/Water ElHAMMERlDRIVEN CASING THICKNESS TYPE Of CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE El MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑.RIPE <br /> _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ❑INJECTION(.e.Air s-arae.ozonel[].HAND AUGER GROUT SPECIFICATIONS <br />�. --❑OTHER: ❑OTHER: .. APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> t NOTE: OFFSITE WELLS $ BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: <br /> DESTRUCTION METHOD: CHECK ALL THAT APPLY - <br /> -#OF W ELL(S)Tc�E DESTR�gvED f •r ®OVER-BORE DIAMETER OF INCHES 7O DEPTH OF FT <br /> WALL IDS: MW-2' MW-27, MW-4 'rl.L- �� M PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:I2AUGERS ❑HOSE ®PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS c;,--p DjDrQ17Pfi y8ork Plan <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, d all pp'cab/ Calif rnia laws. <br /> s Signed TiUelCompany `Project Manager — PSC <br /> Print Name Paul E. Anderson Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS – <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED 8 DATE ISSUED �� AREA <br /> GROUT IN F I BY FINAL INSPE TION BY DATE <br /> DESTRUC O I F554 TION BY �1.� DATE <br /> 9 COMMENTSIC16NDITIONS: lf1l <br /> 1 <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# <br /> s PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# INVOICE <br /> $125 x'a SSD 'yJ'r y' SR# 60ESa'. <br /> ��7..5 C.�j � S5 R <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-61 01113112 WELLPERMI7 APP <br /> /d0/a <br />