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ECEIVEDFILE <br /> °p4D)N SAN JOAQUIN COUNTY is Copy <br /> OCT 2 Y 20111'3 ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> ca •_' RONI �1�9) 468-3147 Fax: (209) 468-3433 Web:Www.siaov.ora/eh UNIT IV <br /> FOR PERMIT/S VICES <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <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 201610-1650 <br /> C-57 Contractor Advanced GeoEnv. Address 837 Shaw Road City Stockton Lic 680227 Phone 800 511-9300 <br /> Consultant/Sub Cntr Advanced GeoEnv.Address 837 Shaw Road City Stockton Lic 680227 Phone 800 511-9300 <br /> Billable Party Address 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 /> (3 SOIL BORING IDs B1 through B8 <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 <br /> TREMIE TYPE TO BE USED: El AUGERS [I HOSE PIPE <br /> 8 6 SOIL BORING N PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ®No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —El INJECTION(i.e.AirSoaroe Ozone)❑HAND AUGER GROUT SPECIFICATIONS 94 Ib portland cement and 6 gallons water <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 30 feet bsg ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING CKNo ElYes:Casing 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: ElPRESSURE 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) <br /> COMMENTS FT BELOW SURFACE <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prep red this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all applicabl a1ifornia ws. <br /> Signed Title/Company Geologist <br /> Print Name Brian Millman Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS_ ��t�J� :5. CL 0,5Op4D0 5, ' <br /> WORK PLAN DATED 0070&Q 21 2v t "3 <br /> APPLICATION ACCEPTED BY I ,}04t"✓+- ' DATE I AREA /670 <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTIWINFOAMT <br /> FAC# <br /> PE CODESCHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> _ REQUEST PR# <br /> �� 3g 1 7� � u v rye /C7 21-/3 SR# �p 22� O RO# <br /> (3500) <br /> PR# <br /> (2900) <br /> C-57 WC r/ WAIVER Al r4 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOC w'Y <br /> EHD 29-01 01/13/12 <br /> WELL PERMIT APP <br />