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4uln SAN JOAQUIN COUNTY La <br /> — ` ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION <br /> a 1 68 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> Telephone: ( 09)488-3147 Fax:(209)468-3433 Web:Yvww Biaov.oralehd -----'--- <br /> `1Fd W LL & BORING PERMIT APPLICATION <br /> FOR WELLS AND B RINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-1 EFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin Co my for a permit to consirucl andfor install the work descdhed. This application is made in compliance wi01 San <br /> Stockton 95206 APN 163-230-34 <br /> Joaquin couon is h Development Title,Chapter 9 175.3,and the Standards of the San Joaquin County Environmenta�HP alth Depadmen. -- <br /> g. Presno St CllylSlale <br /> 1245 N. Charter Ny ossStreet 95361 209-848-3272 <br /> Site Location cily/slale0akdale2ip Phone�.--,-- <br /> Property Geo Properties, Inc- ddress2306 Jackie Ct 2 9 209-369-9600 <br /> Owner- <br /> 7V—&WStockton Lic Phone <br /> Drilling ddross3806 Duck Creek Drarylslate L aic ,ng_g9�-4119 <br /> C-57 contractor _-__,____---- AVe CilylState"•""a . .--Phone — <br /> ntrGZA, Inc. dress T T �� Kansa 1 <br /> Consuean Party <br /> Geo Prop <br /> Billable Party ddress 2306 Jackie Ct CilylState Oakdal ep95361 Phone209-848-32 <br /> GIS Coordinates:X <br /> 37 .9367 Y 121 .3046 <br /> CONSTRUCTION WORK TO BE PERF RMED: <br /> NEW WELLIBORING(GPT,GEOPROBE. DROPUNCH.HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs - - <br /> UrOTHERIDs TniarYTOn - - <br /> TYPE&#OF WELUBORING yIN�yS�AL1 TION TYPE CONSTRUCTION SPECIFICATIONS❑MULTLE CASINGS OMULTI-LEVEL WELL CASING DIA: <br /> &kOLL STEM DIA.OF BOREHOLE <br /> _❑MONITORING CASING THICKNESS 4CH R O TYPE OF CASING: ❑STEEL 6 PVC ❑ OTHER <br /> _❑EXTRACTION:Vapor/Water ❑HAMM R/DRIVEN <br /> _❑SOIL VAPOR PROBE ❑MUD OTARY DEPTH OF GROUT SEAL 1 'i +-t TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE PIP <br /> _❑SOIL BORING ❑PUSH INT(GPl CPT) <br /> OR SEAL PUMPED: nO b0(tMAXIMUtMeFREE FALL DEPTH IS 30 FT) <br /> p I❑HAN UGER GROUT SPECIFICATIONS <br /> 3❑INJECTION h a s 2 5 ft L7j00LTED TRAFFIC BOX OR (:3 STOVE PIPE <br /> O OTH APPROX.BORING DEPTH--_ Bodng Die:_,_ <br /> _I]OTHER: 6x( Casing DeDlh:__ <br /> CONDUCTOR CASING u No❑Yes:Casing <br /> la: <br /> COMMENTS: Refer o Ph e II <br /> mnati n <br /> NOTE: OFFSITE WELLS BORINGS REQUIRE ACCESSDESTRUCTION <br /> ASRR cMoN METHOD'ENTSENCROACHMENT ECK ALL AT PERMIT <br /> DESTRUCTION WORK TO SE PERF RMED: ❑OVER-BORE DIAMETER OF INCHES TO DEPFTTHB BELOW SURFACE <br /> _#OF WELLS)IV BE DESTROYED ❑PRESSURE GROUT TO DEPTH OFTO FT BELOW SURFACE <br /> WELL IDS: ❑EXPLOSIVES FROM FT BELOW SURFACE <br /> GROAT SPECIFICATIONS ❑MUSHROOM CAP AT L>3FT) <br /> TREMIE TYPE TO BE USED:❑AUGER ❑HOSE []PIPE <br /> COMMENTS <br /> 5 WORKING DAYS NOT CE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENT <br /> 1 hereby certify that I have pared th pplication and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and al p aIsC or alaws. TIIIeICompany PG, Ground Zero Analysis, Inc. <br /> Signed Ph.D. Data <br /> Print Name Ray old Kabl ow II, <br /> DEPARTMENT USE ONLY <br /> Way <br /> SITE MAP IN UNIT IV FILE-SITE ADD SS 211 <br /> y ' <br /> WORK PLAN DATED DATE��IS.SUF� x' 19- l4 AREA�� <br /> APPLICATION ACCEPTED BY 1, FINAL INSPECTION BY 10 L: mA�dni'hffZr. DATE <br /> �Cltl 1 <br /> GROUT INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY .-- t a-----e,+;--- S w- - <br /> COMMENTSICO NDITION S: <br /> ACCOUNTING ONLY: AID <br /> FAC# SERVICE RO# INVOICE I <br /> RECV-D BY DATE REQUEST PR# <br /> PE CODES FEE INFO AM REMITTED CHECK# 3 ' SR# 4, 24 <br /> 350 $125X 3375-, 00 230 ✓ <br /> R 00 O.7407 <br /> v 1 <br /> 5o3 5.00 PR# <br /> 0 12900) <br /> WC WA R I C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC— <br /> C-57ERMIT APP <br /> EHD 29-01 5/09112 <br />