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o.PR`'"y•.c SAN JOA UIN COUNTY `' <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> a• a <br /> N: < <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> p.. <br /> Telephone: 209 468-3147 Fax: 209 468-3433 Web:www.sigov.orq/eh UNIT IV <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 ziD 95206 APN 147-071-071 <br /> Property Knife River Corporat gf6s PO Box city Stockton zip 95206 Phone 948 0302 <br /> Owner <br /> Ow <br /> C-57 Contractor All Well AbondrnnW45 Beatty Drive Suiteit�\ Sacramenit0 848359hone 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 3-7, 9 3 S Y -1 L 1. �2,4 4 / <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> [X 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 El HOLLOW STEM DIA OF BOREHOLE 8 El 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 30 TREMIE TYPE TO BE USED: (.AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED[XYes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> t2[x INJECTION(i a Air Sparoe Ozone)❑HAND AUGER GROUT SPECIFICATIONS nn rtla n d <br /> ❑OTHER ❑OTHER: APPROX BORING DEPTH 45 feet ]BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> Cp�r� cT%CASING❑No❑Yes:Casing Dia: Casing Depth: Bonng Dia: <br /> COMMENTS.-Ozone Sparge WeIIS OS-5 t0V.7- I t7 <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,andall Applicable C ;fornia laws. <br /> Signed W l Title/Company Geologist/AGE <br /> Print Name William Little Date 12/23/13 <br /> DEPARTMENT <br /> gUSE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 3 / w, <,4# STI�E- , <br /> WORK PLAN DATED T - <br /> APPLICATION ACCEPTED BY DATE ISSUED /4,31 "1 AREA /6 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# INVOICE <br /> PE CODES FEE INFO AMT REMITTED C7=1 <br /> HECK# RECV D BY DATE REQUEST PR# <br /> 35 1 $10r �5� 7S 3�'S 1 7 2,>L'r /,21-1 SR# 6Z8 <br /> RO# <br /> (3500) <br /> PR# <br /> (2900) <br /> C-57 ✓ WC t✓ WAIVER A, Y�- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENTi�DLO PER <br /> EHD 29-01 01/13/12 <br />