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.o ur c � • F <br /> aSAN JOAQUIN COUNTY � -Y� <br /> N ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> - SITErMIT.IGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 �,;,, <br /> . �;•. ;p Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:wii�bww.sigov.orq/eh "IJNFT l�/ <br /> WELL & BORING PERMIT APPLICATIONROIV NDAL�tl;AILTl_. <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIOM'1vIrES <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 Zip95219 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�-CC�•ntr Advanced GeoEnv.Address 837 Shaw Road City Stockton Lic 680227 Phone 800 511-9300 <br /> Billable Party G�'S�l) lell+P✓`100 Address 16 _& S e 1 FjC � ,/' City Phone X4_70 —71 5 <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 /> I3 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 ❑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 in PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ®No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.AirSparge.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: OND TOR CASING FX No 171 Y acing Dia' Casing Depth Boring 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 FT) FT BELOW SURFACE <br /> COMMENTS <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 'fable Cal'ornia laws. <br /> Signed �— 7L," Title/Company Geologist <br /> Print Name Brian Millman Date & ` <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS �(� U E� D_-2 bd ST 57 <br /> WORK PLAN DATED SEPT^►ScE� 2pl�! <br /> APPLICATION ACCEPTED BY - L/du�Yl DAT - AREA /G-q9 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE -'31 <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 /> �71to�- $ x / /O�0 l doGCNJ �-�l'-1 LI SR# 7v�rG Z <br /> jp J�b RO# <br /> J (3500) <br /> PR# <br /> (2900) <br /> C-57 t/ WC l/ WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOCIVq <br /> EHD 29-01 01/13/12 WELL PERMIT APP <br />