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SAN .JOAQUIN COUNTY ORIGINAL <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> • - 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATIONUNIT IV <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/eh <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 639 West Clay Stross Street city Stockton zip 95206 APN 147-071-071 <br /> Property Knife River Cor ora 95206 09 948 0302 <br /> Owner p tal62ss PO Box city Stockton zip Phon <br /> C-57Contractor All Well Abondrna6cls245 Beatty Drive SuiteitSacramenit,O 848358hone 916-363-9355 <br /> Consultant/SubCntr AGE Address 837 Shaw Road city Stockton Lic Phone 467-1006 <br /> Billable Party AGE Address 837 Shaw Road city Stockton zip 95215 Phone 467-1006 <br /> GIS Coordinates X 37 913 c1 S Yl 2-1. 29 G 1 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> IM NEW WELL/BORING(CPT.GEOPROBE HYDROPUNCH,HAND-AUGER.OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDS <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA OF BOREHOLE 8 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA. One Inch <br /> _❑EXTRACTION Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 30TREMIE TYPE TO BE USED [AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:(RYes ❑No(MAXIMUM FREE FALL DEPTH IS 30 Fly <br /> t2(x INJECTION(,. Ir Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS portly nd <br /> _❑OTHER: ❑OTHER APPROX BORING DEPTH 45 feet �(]BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: we <br /> e ar <br /> Ozone Sparge I nlls OS-5 to bW01%CASING❑No❑Yes: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: ❑ 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,andal pplicable Qaiiifoia laws. <br /> W <br /> Signed Title/Company Geologist/AGE <br /> Print Name William Little Date 12/23/13 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS �0 3`f W, eL y 5 TI�6 7-, 57Z'k—ekn'v <br /> WORK PLAN DATED -24)f 3 <br /> APPLICATION ACCEPTED BY DATE ISSUED ­Y AREA /6 <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 /> 35 1 $125 x /Z i500"� 7s -( SR# cj�08RO1 <br /> 3�9 3 3 S 3�S (35500) <br /> PR# <br /> (2900) <br /> C-57 t- WC 1/ WAIVER A.1 4 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC—A/19- <br /> EHD 29-01 01/13/12 WELL PERMIT APP <br />