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° DIN SAN JOAQUIN COUNTY <br /> �O•�t.CDG _. <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> Telephone: (209) 468-3454 Fax:(209)468-3433 Web: www.sioov.org/ehd UNIT IV <br /> FIFO <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 1947 E. Channel St cross street E. Miner city Stockton Zip 95205 APN 153-120-02 <br /> Property <br /> owner Tina's Investing Inc.— <br /> nc Address 2715 W. Kettleman city Lodi Zip95242 Phone209-570-1815 <br /> C-57 ContractorAdvanced GeoEnvironmenta�dress 837 Shaw Road Stockton 680227 209-467-1006 <br /> a City Lic Phone <br /> 209-467-1006 <br /> C; Vanced GeoEnvimnmen%dress 837 Shaw Road <br /> City Stockton Dc 680227 Phone 209467-1006 <br /> ' Billable Party Tina's Investing, Inc. Addre4715 W. Kettleman, Suite 203-31�ity Lodi Zip 95242 Phone 209-570-1815 <br /> GIS Coordinates:X 37•1IG <br /> _ 811/ Y- 121- 2G$Cx{ <br /> CONSTRUCTION WORK TO BE PERFORMED• <br /> ' ®NEW WELLJBORING(CPT,GEOPROBE,HYDROPUNCH,HANDAUGEROTHER) <br /> 91 SOIL BORING IDs Bi, B2. B3, B4,SV1, SV2 <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> ' TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 112s ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> _❑EXTRACTION:Vapor/Water [IHAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _ <br /> b SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Up t0 20' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> LN SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes IN No(MAXIMUM FREE FALL DEPTH IS 30 Fri <br /> __El INJECTION Qe Air Soame Dame)❑HAND AUGER GROUT SPECIFICATIONS Type 1/II, neat cement <br /> _O OTHER: ❑OTHER: _APPROX.BORING DEPTH Up f0 20' — 0 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING❑No[IYes:Casing Dia: Casing Depth:_ Boring Dia:__- <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> ' DESTRUCTIONWORKTO BE PERFORMED: -- ---- - DESTRUCTION METHOD•QjjECK ALL THAT APP Y) <br /> _#OF WELL($)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUTSPECIFICATIUNS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE I]PIPE ❑MUSHROOM CAP AT(>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,and I applicable GaIt orniq�aws. <br /> Signed / L mPanY President,Advanced GeoEnvironmental <br /> R Bert Ma , Title/Co <br /> Pdnt Name 02/24/2015 <br /> Date <br /> ' p'/y DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE DRESS_ l ('( Ip d7<RNAX—L ST 7-I ,STeje t7Z ) <br /> WORK PLAN DATED_ F R♦;u A 2r/ 2 2DP' ' <br /> ' APPLICATION ACCEPTED BY 1 DATE ISSUED 1-17-15 AREA --- <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY - DATE <br /> ' COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> REQUEST I PR# <br /> $ <br /> z4o3 390 /7ztiz �u�r zu r{ SR /U <br /> t (3500) <br /> PRR# <br /> � � 2900 <br /> EHD729-0i�07128/10 `/ WAIVER 7v C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC All) <br /> ' WELL PERMIT APP <br />