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o D SAN .JOAQUIN COUNTY • FILE COP Y <br /> p4Urp <br /> APR 19 2011 ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> Q: a <br /> NVIHONMENT HEALTHOO East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> ° P PEHIM'"WIMM09) 468-3454 Fax: (209) 468-3433 Web:www.sigov.org/eh UNIT IV <br /> 9(r FOR <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 Locator 3655 Cherokee -Cos.Street Newton Rd City Stockton Zip 95205 APN 132-060-09 <br /> Property <br /> owner_ehe!{e4 CeCChini, et . iiiijiJress 3000 E 18th St city Antioch zip 94509Phone925-742-2058 <br /> C-57 Contractor AGE Address 837 Shaw Rd City Stockton Lic 680227Phone 209-467-1006 <br /> Consultant/Sub Cntr Address City Lic Phone <br /> Billable Party AGE Address 837 Shaw Rd Citystockton Zip 95215 Phone209-467-1006 <br /> GIS Coordinates:X 3 Y"121. Z55 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> fq NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> P9 SOIL BORING IDs <br /> ❑WELL IDs _ <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 1 •, <br /> —[:]MONITORING D HOLLOW STEM DIA.OF BOREHOLE 2 1nh%bLTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA. �W <br /> _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS na. TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER L A <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 3 0 f ee'A,EMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE `\ r•� <br /> 1619 SOIL BORING M RUSH POINT(GP/CPT) GROUT SEAL PUMPED'.0 Yes IS No(MAXIMUM FREE FALL DEPTH IS 30 FT) V` <br /> _O INJECTION IieAirSoarae.Ozone)OHAND AUGER GROUT SPECIFICATIONS pOrtland <br /> _0 OTHER: 0 OTHER: APPROX.BORING DEPTH 30 feet ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE /.. <br /> CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth: Boring Dia. 1n1 <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 WELLS)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 /> n <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations�,�apn'd/nee/a/�/y'.a�_p,plica le lifornia laws. <br /> Signed t/tALr�/1�1-rainy Title/Company Geologist / AGE <br /> Print Name William Little Date 04/19/2011 <br /> DEPARTMENT USE ONLY Z4-556 <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS -:16 E• C /EA <br /> WORK PLAN DATED 7 )VII"1Z <br /> APPLICATION ACCEPTED BY DATE ISSUED •Z AREA 0(10— <br /> GROUT <br /> E+SGROUT 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 RRO" INVOICE <br /> V ��ii /��•-} REQUEST PR#p <br /> 2`tb $122 x 1 *! (L Z 7,(oQ v C w� 19 11 SR# D L O <br /> 2q 0 � 31t� 366 RO# <br /> 3500 2' ` <br /> 29 0 052 Z J <br /> C-57 WC WAIVER_ _ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 WELL PERMIT APP <br />