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C <br /> Pa`"K. SAN JOAQUIN COUNTY 00 [PY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> y: x SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202 3029 UNIT IV <br /> • ..• -- ;t, Telephone: (209) 468-3147 Fax: (209) 468-3433 Web. www.slgov.org/eh <br /> 4 jF••Rta <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 147-071-07l <br /> perry Knife River Corporat Bass PO Box city Stockton zip 95206 Phone 948 0302 <br /> Ow <br /> Owner <br /> C-57 Contractor All Well AbondrnnW45 Beatty Drive Suite;t� Sacramen;i0 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 +3 5 Y —1 2. <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ® NEW WELUBORING(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 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA One Inch <br /> _❑EXTRACTION:Vapor!Water ❑HAMMER/DRIVEN CASING THICKNESS <br /> 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(GPI CPT) GROUT SEAL PUMPED:[Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> land <br /> 1 2[X INJECTION(i a Air Soarae Ozones❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER, C]OTHER APPROX BORING DEPTH 45 feet BOLTED TRAFFIC BOX OR C]STOVE PIPE <br /> C C CASING❑No❑Yes:Casing Dia: Casing Depth Boring Dia: <br /> COMMENTS- Ozone Sparge wells OS-5 to - <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 /> ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> WELL IDs: ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> GROUT SPECIFICATIONS MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED F1 AUGERS E] HOSE ❑ PIPE ❑ <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 al),applicable Ca;fornia laws. GeOIOgISt/AGE <br /> SignedIli Title/Company <br /> Print Name <br /> William Little Date 12/23/13 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 3 �� 5 T(�6 7-, <br /> WORK PLAN DATED <br /> I olrKk v� <br /> DATE ISSUED �-��'� AREA /6 <br /> APPLICATION ACCEPTED BY <br /> FINAL INSPECTION BY DATE <br /> GROUT INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# <br /> PC)I $,z5x jz iSW� 875 3851 C'�ur l,�-I sR# (a�8/ <br /> 2 RO# <br /> �� J 3 37i (3500) <br /> PR# <br /> (2900) <br /> C-57 ✓ WC ✓ WAIVER�✓ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT/�DOCLL PE� <br /> EHD 5-01 01/13/12 <br />