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4uly SAN JOAQUIN COUNTY <br /> �a-�••� FILE COP Y <br /> a ,. ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> t oR>:P Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.siaov.orcI/ehd 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 Countt,�{? oel?Pment Title Chalpter 9-1' 5.3 and the Standards of the San Joaquin County Environmental Health Department. <br /> loo 0010 s. street 4 3oa-s a eaac c rtes way <br /> [ --� ^ 1/ charter way and California Street Stockton 95306 <br /> Site Location 1�'+ ` 06WRz ss Street City/State Zip ApN 167-150-33 <br /> Property <br /> Owner mayea Cuevas Address sad east Charter way City/State stookcon Zip 95306 phone 209-4e1-9950 <br /> Advanced GeoEnvil Inc, a3] Shaw x000 <br /> C-57 Contractor Address <br /> City/State Stockton LIe 690227 Phone 209-467-1006 <br /> Advance�eo nvir menTine. <br /> Consultant/Sub Cntr Address ell Shaw Road City/State Stockton Lic 690227 Phone 209-497-1006 <br /> Billable Party Advanced Geeenvircn ental 3ncAddress 837 Shaw Road Chy/State Stockton Zip 95215 Phone 209-467-1006 <br /> GIS Coordinates:X �7 911542. ( `/2/, 2 c%57 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> IE SOIL BORING IDs Bl, B2, 38 <br /> ❑WELL IDs <br /> ❑OTHERIDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 125' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _O EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 15-40 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE 0 PIPE <br /> a 0 SOIL BORING In PUSH POINT(GP/CPT) GROUT SEAL PUMPED:(9 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION 0a.Atr SBame Ozone El HAND AUGER GROUT SPECIFICATIONS e.r[l.nd cement (6 gallon. of water per 94 lbs bag of cement) <br /> _I]OTHER: ❑OTHER: APPROX.BORING DEPTH 35-40 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia:_ <br /> NOTE: OFFSITE WELLS & 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 ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑ PIPE ❑MUSHROOM CAP AT L3 Fr) 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 plicable California laws. <br /> Signed Title/Company Breieca Geologist/Ace <br /> Print Name Basial Villanueva Date 01 ,July 2014 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 5 Cy CeAfigo-rZ X41 S7k 7M_n) 1 <br /> WORK PLAN DATED 7- -1 <br /> APPLICATION ACCEPTED BY eI•GJ C)n3 r,wwl DATE I Ll,AREA' /6 <br /> GROUT INSPECTION BY FINAL INSPECTION BY NII DATE 2 •/ <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 /> $125X I UG E.cei 7-/-/y sR# 70oao <br /> 2C(O� 37S RO# <br /> 3500 <br /> PR# <br /> (2900 <br /> C-57 v WC ✓ WAIVER A44 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT L/ ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />