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" SAN JOAQUIN COUNTY y <br /> ,o „ ..... co F e <br /> Q• .,a <br /> ENVIRONMENTAL HEALTH DEPARTMENT app <br /> �,; e <br /> '• 600 East Main Street, Stockton, CA 95202-3029 jS�TE,tMIT,IGATION <br /> ••�q•.;;•,,;:.••�Q' Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.orq/eh UNIT <br /> ,CfFDR� •/ <br /> WELL & BORING PERMIT APPLICATION '01* ENDiL <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION -PV!( R <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 800 511-936-0-- <br /> Consultant/Sub CCntr Adva//ncedLLGeoEnv.Address 837 Shaw Road City Stockton Lir 680227 Phone 800 511-9300 <br /> Billable Party �p��t) I ��'FiP�i`IL1 Address I LS U 5 v 1 i%U yk19/ City_ v� :'� Zip G i�Jw Phone L470 <br /> GIS Coordinates:X 37.935605 Y -121.28482 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> 2 SOIL BORING IDs B4 through B7 <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _O 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 IN No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.Air Sparge.Ozone l❑HAND AUGER GROUT SPECIFICATIONS 94 Ib portland cement and 6 gallons water <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 3 and 40 feet bsg ElBOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING r%Non Yes Casing Dia' Cacing 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 ATL>3 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 appfji6ble California IajNs. <br /> Signed <br /> — Title/Company Geologist <br /> man <br /> Print Name Bri n MillDate 1 <br /> / _ DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS /&5v S, El- Dra,+bd S_r, 57?>0&raHJ <br /> WORK PLAN DATED SEPTEM SG/Er�1 G ZU/ q <br /> APPLICATION ACCEPTED BYDATE ISSUED 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 /> REQUEST PR# <br /> (71 $ x I �O�l �li� `�"u-1`I SR# <br /> X103 J�� RO# <br /> J (3500) <br /> PR# <br /> (2900) <br /> C-57 ✓ WC // WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC A-111V <br /> EHD 29-01 01/13/12 WELL PERMIT APP <br />