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,a�, E" VED6 • FILE Copy <br /> o.? ••.c SAN JOAQUIN COUNTY <br /> OCT 2, 1 2013 ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> ` SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> IRON R���� 19) 468-3°147 Fax: (209) 468-3433 Web:www.sigov.org/eh UNIT IV <br /> PERMITIS 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 4202 Bass Road Stockton Zi 95219 Phone 209 610-1650 <br /> Owner Address City p <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 131 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[I MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor]Water ❑HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> —C]SOIL VAPOR PROBE ElMUD ROTARY DEPTH OF GROUT SEAL Entire TREMIE TYPE TO BE USED: ❑AUGERS F]HOSE PIPE <br /> 8 6 SOIL BORING Ill PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ®No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i a Air Sparge.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 /> CONDUCTOR CASING IXNo❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <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 applicabivclalifornia 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 /(I 5C1 j &fL S`t y <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY J I°��K'r✓' DATE I :TAREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY ATE�Q /�I <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 /> O' $125x 7J0 � 7t' Coccvr*r; /C?��'!3 SR# 62- <br /> 2Ct C) 3 RO# <br /> (3500) <br /> PR# <br /> (2900 <br /> C-57 l-' WC C.-' WAIVER v1l+`r C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOC w <br /> EHD 29-01 01/13/12 WELL PERMIT APP <br />