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y -'I--UtIVE <br /> H�..I . SAN JOAQUIN COUNTY MAY 0 6 2015 <br /> �:NVIR <br /> ENVIRONMENTAL HEALTH DEPARTMENT ONMEN- L H - P <br /> 1666 Hazelton Avenue, Stockton, CA 95205-6232 PERMIT-- WTION <br /> Telephone: (204) 468-3147 Fax:(209) 466-3433 Web:LVWW.sIaDv.Oro/eh 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 permL to construct and/or Install the work descdbod This application is made in compliance with San <br /> Joaquin County Development Title,Chapler 5-1115 3,and the Standards of the San JoagU.n County Environmental Health Department <br /> Site Location 378 W.Dr.MLK Jr Blvd_ Cross Street _S.Van Buren Cily/Stale _Slockton,CA Zip 95206 APN_165 030.16 <br /> Property <br /> Owner MGRP I LLC Address _1936 Seabee Place__ City/State _San Jose,CA_Zip 95133 Phone <br /> C-57 Contractor National EWP® Address J�'16'/ A-f Cit y/SIaIa 0jIfb".%,F/LiC 7/S 3044 Phone aYo- 23&-c,2a- <br /> CH <br /> Consultant/5ub Cntr Slantec� Address 3017 Kilgore Rd.Ste 100 City/Stale_Rancho Cordova,CA L', Phone 916-384.0766 <br /> Billable Party_Stantec Address _3017 Kilgore Rd,Ste 1O0_ City/Slate Rancho Cordova.CA Zip 95670 Phone 916-384-0708 <br /> GIS Coordinates'X Y <br /> CONSTE CT'0" <br /> WORK TO BE PERFORMED: <br /> EW WELLIBORING(CPT,GEOPftOBE,fiYLIROP_-N H.HAND-AUGER,OTHER) <br /> ❑S91L BORING IDs - -/ <br /> [JIVELL IDs rit-Y1"v„ <br /> ❑OTHERIDs / - <br /> TVPE.6 K F W BORIN INSTALLATION TYPE �NSTFFUCTI_ON S-PgE�CIFICATIONS <br /> MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE.'m' ❑MULTIPLE CASINGS❑MULT4LEVEL WELL CAS NG DIA _ <br /> _ ❑EXTRACTION Vaporl Water ❑HAMMERIDRIVEN CASING TWCKNESS`--,-t;I,ti<I X4.0 TYPE OF CASING ❑STEEL Q PVC O OTHER <br /> _❑SOIL VAPOR PROBE O MUD ROTARY DEPTH OF GROUT SEAL­4:�--TREMiE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT GP)CPT) GROUT SEAL PUMPED D-Yes ®No(MAXIMUM FREE FALL DEPTH 15 30 FT! <br /> _O 114JEGTION a e 6�Q HAND AUGER— .. .-_ GROUT SPECIFICATIONS >It Y"a'T-:'f- (=k:'B"r".E'04- <br /> _❑OTHER OTHER.`Jy,: n APPROX.BORING DEPTH ` __-'/ _'[ - C)60OITED TRAFFIC BOX OR STOVEPIPE <br /> PBRllll IrTAR CASING QA-.❑Ye5 C21'ng 0'a'�Casbp Depth Vf Bodnq Dly' 6 - <br /> COMMENTS._'> <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO EE PERFORMED: DESTRUCTION METHOD:rCHECKALL THATAPPLYI <br /> A'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 FTBELOW SURFACE <br /> TREMIE TYPE TO BE USED-❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS - ' <br /> S YwORKING UAT3IVV atuc mCWUlKrU (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 an Joaquin County Ordinances,Rules and <br /> Regulations'.aj"applicabb <br /> Signed —' Title/Company <br /> 9 <br /> Pdj Datant Name r _ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS S`C�F; (.�(.�,o,:Lr{�.t Wr<^�_ <br /> WORK PLAN DATED TU-L I L. u _ <br /> APPLICATION ACCEPTED BY �.!'�'� ORTE I ED / AREA <br /> GROUT INSPECTION BY FINAL INSPECTION B DATE <br /> DESTRUCTION INSPECTIONBY DATE <br /> COMMENTSICONDITIONS: /7 w- J e.,.x a, '112 9 e <br /> ACCOUNTING ONLY. AID Z FAC S <br /> PE CODES FEE INFO AMY REMITTED CHECK R RECV'D BY DATE SERVICE ROWk <br /> EE <br /> PE PRINVOICE <br /> RT <br /> a9�( s13oX .$(a o.o< 4635 C� s�FjFs` SRN <br /> 8 <br /> Re� <br /> 35D0 <br /> PRV <br /> 1211 <br /> �3t'6c6rj <br /> C-57k,' WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> FHn7R41 704114 WFII PFRMrTAPP <br />