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"tUHVED <br /> SAN JOAQUIN COUNTY MAY 0 6 2015 <br /> = ENVIRONMENTAL HEALTH DEPARTMENTFNVIRONMENTALHL4QR1-I <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 PERMm,961MOMIGATION <br /> c •r Telephone. (209) 468-3147 Fax: (209) 468-3433 Web:wwvr-sioov.orQ/eh UNIT IV <br /> F <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 /> Applicalion 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 S Lincoln St ROW and Clay SI ROWI Cross Street _Dr.MILK Jr Blvd_ City/Stale Stockton,CA Zip 95206_ APN„N/A,-_ <br /> Property <br /> Ownar_C8y of Stockton_ Address CitylStote Stockton,CA_Zip Phone <br /> C•57 Contractor _National EWP_ Address !40 Al4E.ry At-( Comm Lic 95.3!.t✓G Phone tilo-Z 3G-�dKz <br /> Consultant/Sub Cnu Stanlec_ Address 3017 Kilgore Rd.Ste 100_ CdylState_Rancho Cord a,CA Lic one 915-384-0766 <br /> Billable Party_Stantec Address 3017 Kilgore Rd,Ste 100_ City/State _Rancho Cordova.CA Zio 95670 Phone 816-384.0708 <br /> GIS Coordinates X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> G-IJEW 11,FELLIBORING(CPT G%TB ,HY�pROP�'UNC1�,2N AUGER OTHER) <br /> Q SOIL BORING IDs LbjLL.- (S <br /> ❑WELL to <br /> ❑OTHER IDs <br /> TYPE&NOF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ^❑MONITORING D HOLLOW STEM DIA OF BOREHOLE_ Q MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA- <br /> _Q EXTRACTION Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING Q STEEL Q PVC Q OTHER <br /> _r-)SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED Q AUGERS ❑HCSE PIPE <br /> 2_[2"SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED Q Yes Q No(MAXIMUM FREE FALL DEPTH IS 70 FT) <br /> _Q INJECTION le Atr Secme (be 0HAND AUGER GROUT SPECIFICATIONS <br /> 1.. y� <br /> �Q OTHER. 'OTHER.( r U r't-1 't'=+aAPPROX,BORING DEPTH Q BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> " .1� cnuni rrnp CASING[DNo Q Yes Casing Die- Casing Depth'_ Boring Dia._ <br /> COMMENTS,-* SE?L Ctrl r C, (�l in-0 Le <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCT IOK WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALL THATAPPLY) <br /> NOF WELLS)TD BE DES DYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL OrsS Yl'i Vll SSURE GROUT TO CEPT i 0i • 5 FT BELOW SURFACE <br /> GROUT SPECIFI :AT!ONS5e-d' EXPLOSIVES FROM To FT BELOW SURFACE <br /> TRENVE TYPE-"` ""^ r' "^cepc rI untc rd-cloe ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS=rS.0 1z�-OLC - <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby cerlfy that I have prepared this applica0on and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and 1 applicable—Calif�oml-a laws. <br /> Signed �� / G� TbklCompany Qp5 5uee/V( or NA-i1UNA-L ,P <br /> Print Name CAQ'ly Date Lj. 3c l5� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY c�Vt DATFyISSUED _. AREA <br /> GROUT INSPECTION BY FINAL INSPECT IO BY DATE <br /> DESTRUCTION INSPECTION BY DATE 7 <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY'. AID Y FAC N <br /> PE CODES FEE INFO AMT REMITTED CHECK N RECV'D BY DATE SERVICE RD N INVOICE <br /> REQUEST PRN <br /> /) 13 l3- <br /> `I G' 2 5 130 z cC> "— E�5 �� �1.1' `� SRN <br /> C 35 <br /> X "`� 000 Z.Z.z/ <br /> 2900 53 4" <br /> C-57,'� WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> PHn 7g Jit 7U4/t! WFI I PFRMIT APP <br />