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+� FILE COPY <br /> oRq�!n...� SAN JOAQUIN COUNTY <br /> x•-fit .o <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> �4•..�;-. ;P Telephone:(209) 468-3454 Fax: (209)468-3433 Web:www.sociov.org/ehd UNIT IV <br /> �rFOR <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. Minercity Stockton zp 95205 APN153-120-02 <br /> Property <br /> Owner Tina's Investing Inc Address 2715 W. Kettleman city Lodi zip 95242 Phone 209-570-1815 <br /> C-57 ContractorAdvanced GeoEnvironmentiAddress 837 Shaw Road City Stockton Lic 680227 Phone209-467-1006 <br /> Consultant/Sub&Vanced GeDEnvironmen%dress 837 Shaw Road City Stockton Lic 680227 Phone 209-467-1006 <br /> Billable Party Tina's Investing, Inc. Addres�715 W. Kettleman, Suite 203-31�ity Lodi Zp 95242 Phone 209-570-1815 <br /> GIS Coordinates:X j j 88 !S Y <br /> CONSTRUCTION WORK TO BE PERFORMED• <br /> ®NEW WELUBORING(CPT,GEOPROBE HYDROPUNCH,HAND-AUGER,OTHER) <br /> ®SOIL BORING IDS B1, B2. B$, B4, SVt, SV2 <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1.25 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> �� yy❑..,,EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: EI STEEL I]PVC p OTHER <br /> =y SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL up to 20' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> 4 M SOIL BORING ❑PUSH POINT(GP/CP) GROUT SEAL PUMPED:❑Yes [9 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION(ja Nr Sname,o 1❑HAND AUGER GROUT SPECIFICATIONS Type 1/11, neat cement <br /> _O OTHER: ❑OTHER: APPROX.BORING DEPTH up to 20 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth:_ Boring Dia:_ <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTIONWORKTOBEPERFORMED: - - DESTRUCTION METHOD,(CHECK ALL THAT APPLY) -- <br /> _#OF WELLS)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 ❑EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) <br /> COMMENTS 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,ancol appljcabLa.G2liforni aws. <br /> Signed �.�� President,Advanced GeoEnvironmental <br /> 9 Title/Company <br /> Print Name R bert Malyy Data 02/24/2015 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IVFILE-SITEA DRESS /9L(' C, IIMA4615-L 57 -I5 -eCT <br /> WORK PLAN DATED ZOf <br /> APPLICATION ACCEPTED BY _I. d^ulkuu4 DATE I, Eq <br /> GROUT INSPECTION BY FINAL INSPECTION BY ` A 3 <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 RO# INVOICE <br /> REQUEST I PR# <br /> �Qos s / r7z1z amu, r>� zu-lam SR# 716/ <br /> z4o3 3yo RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 I,' 0 WAIVER�4-- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOCS <br /> EHD 29-01 07/28/10 WELL PERMIT APP <br />