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ip <br /> SAN JOAQUIN COUNTY MAY 0 6 2015 <br /> ENVIRONMENTAL HEALTH DEPARTME T I "T 01NL,,IEIVTAiSt, LOIPATION <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 PER",41T//S� �§SITTe%phone: (209)468-3147 Fax: (209) 466-3433 Web:M WWW.sfaov.Oraleli RyIr;ESLN'(T 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 conslrua and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Tole Chap(er&1115 3,and the Standards of the San Joaquin County Environmental Health Department <br /> Site Locallon 310 W.Dr.MLK Jr Blvd_ Crass Street _S Van Buren Cily/State _Stockton,CA Zip 95206 APN_165-030-07_ <br /> Property <br /> Owner Centro Man Inc/Mel Young_ Address _6333 Parc Avenue Chy/Slate_Stockton,CA Zip 95207 Phone <br /> C•67 Contractor National EWP_ Address 61,j 11h-e Clty/Stale&LLwilic 43�M, Phone <br /> Consultant/Sub Cntr Slanlec Address 3017 Kilgore Rd,Ste 100_ Clty/Stale_Rancho Cordova,CA Lk: Phone _916.384.0766 <br /> Billable Party_Stantec Address 3017 Kilgore Rd,Ste 100_ City/State Rancho Cordova,CA Zip 95670 Phone 916.384.0708 <br /> GIS Coordinates.X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> EW WELUBORING(CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER) <br /> WL BORING IDs <br /> LL IDs 1- LL- 11A.- LO . <br /> 0 OTHER IDs c G <br /> P��/,I F WELUB RIN INSTALLATION TYPE C sTRUCTION SPECIFICATIONS .;p� <br /> „LH'MONITOR MMG Q HOLLOW STEM CIA,OF BOREHOLE, Q MULTIPLE CASINGS❑MULT4LEVEL WELL CASING DIA - n. - <br /> _Q EXTRACTION Vapor/Water Q HAMMERIDRNEN CASING THICKNESS - L "v,4 4t7 TYPE OF CASING Q STEEL Q PVC Q OTHER <br /> _Q SOIL VAPOR PROBE Q MW ROTARY DEPTH OF GROUT SEAL��+, _TREMIE TYPE TO BE USED' <br /> 1❑AUGERS Q HOSE [.`PIPE <br /> _C SOIL BORING Q PUSH POINT(GP/CPT) GROUT SEAL PUMPED LO Tes Q No(N,AXe4UM FREE FALL DEPTH IS 20 FT) <br /> _QINJEC7ION I%a Arsoeme pxmatQ HANCAUGER GROUT SPECIFICATIONS 117 L'GLI <br /> _C]OTHER:_OTHER: OTHER. L`)�l�f' APPROX.BORING DEPTH ?r Q BOLTED TRAFFIC BOX OR Q STOVE PIPE <br /> coMMENrs'kSNl? cA­-j--{ztGlICut -�MkiV- <br /> ^^•,^ ,^•^^",SING LJmo/❑Yes.C-ShN Dig /Ull Casinp Depen 4 L Boring Die."L'4 <br /> NOTE: OFFSITE WELLS 8 BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTIQU WOR PERF RM D: DESTRUCTION METHOD:(CHECK ALL THAT APPLYI <br /> p OF,W (S)TO BE DES DYED 0 OVERBORE DIAMETER OF NHES TO DEPTH OF FT <br /> WELL e. - RESSURE GROUT TO DEPTHO- - 1 7 FT BELOW SURFACE <br /> GROUTSPECIFICATIONS 'LA. %%'7' EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYP`'` " '-' ""'• '-'" - �"' ❑MUSHROOM CAP AT >3 <br /> p� FT)_Fr BELOW SURFACE <br /> COMMENTS s fDf CA ff-6iGl' 41' tZk JIQ. <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,Widal(applicable CtAforrtla IEWS. <br /> Signed TdINCompany <br /> Print Name �, a Date 17,2M <br /> DEPARTMENT USE ONLY ; 3J <br /> SITE MAP IN UNIT IV FILE•SITE ADDRESS 51'7?, 1A.) r jAC Lt-_+-Y,. <br /> WORK PLAN DATED ?rr 1 `j <br /> APPLICATION ACCEPTED BY (Atka.,!' • _ DATEJB�UED� EA <br /> GROUT INSPECTION BY -� FINAL INSPECTION Bl/ / DATE 7 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: / 4w— s <br /> ACCOUNTING ONLY AID# FAC N <br /> PE CODES FEE INFO AMY REMITTED CHECK a RECV'D BY DATE SERVICE RO a INVOICE <br /> REQUEST PRO <br /> ick s13DX X16 !07 SRIFZ)Sr5- <br /> 35000 PRN <br /> ZZ21 <br /> 2906 S3t:6$9 <br /> C•57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> FHn Pa.a1 712414 WF(I PFRMrT APP <br />