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17i <br /> p4u`N\' SAN JOAQUIN COUNTY <br /> N ENVIRONMENTAL HEALTH DEPARTMENT r✓oP ` <br /> _'S►TErMIT,IGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.si9ov.orq/eh UNITUIV <br /> WELL & BORING PERMIT APPLICATION ' Erriri,, '�R �'F,� LII; <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION"- CF,, <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application 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 1650 S EI Dorado St Cross Street East 3rd St City Stockton Zip 95206 APN 167-032-13 <br /> Property Edmond Pimentel <br /> Owner Address 4202 Bass Road City Stockton Zip 95219 Phone 209 610-1650 <br /> C-57 Contractor Advanced GeoEnv. Address 837 Shaw Road City Stockton Lic 680227 Phone 800 511-9300 <br /> Consultant/Sub CCntr Advance�d�"GeoEnv.Address 837 Shaw Road City Stockton Lic 680227 Phone 800 511-9300 <br /> Billable Party &kfl,)U (2?0+P✓`10k Address 16,S72 S el t%0 kL'/i City Zip Phone <br /> GIS Coordinates:X 37.935605 Y -121.28482 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> [$SOIL BORING IDs B4 through B7 <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Entire TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE PIPE <br /> 4 6 SOIL BORING N PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes I&No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS 94 Ib portland cement and 6 gallons water <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 3 and 40 feet bsg❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING Dr No F1 Yes Casing Dia' Casing Depth Raring Dia <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #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 FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑ PIPE ❑MUSHROOM CAP AT >3 <br /> COMMENTS FT) FT BELOW SURFACE <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,and all ap Viable Calornia laws. <br /> Signed Title/Company Geologist (, <br /> Print Name Bridn I illman Date 1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS S Cl_ 571�,*&rZl t <br /> WORK PLAN DATED SEPT�r G zp!�l c, <br /> APPLICATION ACCEPTED BY —� ya .,Y1 DATE ISSUED 1-3U-74Y AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> G L�, REQUEST PR# <br /> 1 `�� $ x / 10lam'l d,%( ) 9-�1'-/L-( SR# 7v�rG Z <br /> jp 2�O RO# <br /> J (3500) <br /> PR# <br /> (2900) <br /> C-57 ✓ WC _WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC/V� <br /> EHD 29-01 01/13/12 WELL PERMIT APP <br />