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t4Mlry,, <br /> SAN aIOAQUIN COUNTY <br /> E VIRONMENTAL HEALTH DEPARTMENT LOP <br /> r 1 t 68 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone:( 9)468-3147 Fax:(209)468-3433 Web:www.saoov.ora/ehd UNIT IV <br /> WE LL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BC RINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to Son Joaquin Cour y 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 9-1'15.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 1245 N. Charter wy Cr sSlreel S. Fresno SL CilylSlale Zip APN Stockton 95206 163-230-34 <br /> Property Geo Properties, Inc. 2306 Jackie Ct Oakdale 95361 209-848-3272 <br /> Owner A ress City/Slate Zip Phone <br /> C-57Contractor00dwar Drill ' ..P0 Box 336 city/slaw Rio VLo;a L(0710 Phone7o7-374-4300 <br /> ConsultantfSub Cnir GZA, Inc. Adress 1172 Kansas AveCily/Slate MOdestaic 5234 Phone 209-522-4719 <br /> Billable Party Geo Properties Artiness 2306 Jackie Ct city/slate Oakdalelp95361 Phone209-848-3272 <br /> GIS Coordinates:X 37.9367 y - 1.3046 <br /> CONSTRUCTION WORK TO BE PERFO ED: <br /> NEW WELLIBORING(CPT,GEOPROSE,HYO OPUNCH,HAND-AUGER,OTHER) <br /> I]SOIL BORING IDS <br /> I]WELL IDS <br /> ®bTHER IDs <br /> TYPE&#OF WELLIBORING INSTALL N TYPE CONSTRUCTION SPECIFICATIONS <br /> _0 MONITORING {L]1((OLLOW It rEM DIA.OF BOREHOLE 15 n D MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA.' <br /> _O EXTRACTION:Vapod War., 014AMMER/ NEN CASINGTHICKNESS _SfH RO_TYPEOFCASING: OSTEEL I'JPVC 0 OTHER._,_ <br /> _0 SOIL VAPOR PROBE Cl MUD ROTA Y DEPTH OF GROUT SEAL 1 Z F 1- TREMIE TYPE TO BE USED: 91 AUGERS 0 HOSE D PIPE <br /> _❑SOIL BORING 0 PUSH POI (GPI CPT) GROUT SEAL PUMPED:29 Yes D No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> 10 INJECTION 41,A,S,,a Oro„10 HAND AUG ill GROUT SPECIFICATIONS n0 betonite <br /> 0 OTHER: 0OTHER: APPROX.BORING DEPTH 25 ft OBOLTED TRAFFIC BOX OR ❑STOVEPIPE <br /> CONDUCTOR CASING LJ No O Yes I,Dia: Casln90epth:`Baring DW:_ <br /> COMMENTS: ReferS I P IDI 1 i d 11 1 <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORM D: DESTRUCTION METHOD:WHECKALL THATAPPLYI <br /> #OFWELL(S)TOSE DESTROYED [ OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: 0 PRESSURE GROUT Td DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS 0 EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:[]AUGERS ❑I OSE t]PIPE 0 MUSHROOM CAP AT p3 FT)----------.Fr BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE I EQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have p//spared this app callon and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and is law . <br /> Signed oC - '�'p <br /> Title/Company PG, Ground Zero Analysis, Inc. <br /> Pdnl Name Raynold Kablanow II, Ph.D. Date_i - <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED '� DAT SSUED AREA Ons-'y( <br /> GROUT INSPECTION B _ FINAL INSPECTION ATE 31 t14 <br /> DESTRUCTION INSPECTION BY _ _ __ DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID It FAC# <br /> PE CODES FEE INFO AMT REMIT ED CHECK# RECV'D BY DATE SERVICE Rod INVOICE <br /> REQUEST PR# <br /> 3501 $125X 1.2s"00 Q 0 <br /> If <br /> a 00 a9? <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC <br /> EHO 29.01 SM9/12 WELL PERMIT APP <br />