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SAN JOAQUIN COUNTY ' <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> j 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> r„ Telephone. (209) 468-3147 Fax: (209) 468-3433 Web:www.siaov.org/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 zip 95206 APN 147-071-07 <br /> Property Knife River Corpora4gAss PO Box city Stockton zip 95206 Phone 9480302 <br /> Owner <br /> Ow <br /> C-57Contractor All Well Abondrnn&9245 Beatty Drive SuiteityA Sacramenito 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 S Y -/2-/. 29 G / <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 /> —F-1MONITORING F)HOLLOW STEM DIA OF BOREHOLE 8 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: One Inch <br /> _❑EXTRACTIONVapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEALTREMIE TYPE TO BE USED AUGERS El HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:[XYes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> 12(X INJECTION(,a AirSoarae Ozone)❑HAND AUGER GROUT SPECIFICATIONS r)nrf[Ari <br /> _❑OTHER ❑OTHER APPROX.BORING DEPTH 45 feet ]BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> OSparge wells OS-5 to 6'CTQRCASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> Ozone 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 L3 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 1al��,pplicable�CGa Uf�ornia laws. <br /> Signed W""�`A—4-1f�.�s?-- Title/Company Geo logist/AGE <br /> Print Name William Little Date 12/23/13 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS �0 3cj 4), (?/,9� 5 Ti –, K<� <br /> WORK PLAN DATED % <br /> APPLICATION ACCEPTED BYrKK rn DATE ISSUED /—f�-i`S� AREA ld <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 /> 3SC)/ $125x /? 1-00 , 7S 3Q5 )t Cour /.�-I SR# 6081 <br /> Ro# <br /> (3500) <br /> PR# <br /> (2900) <br /> C-57 r/ WC ✓ WAIVER Aj Y�- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOCS <br /> FHn9Q-m M/i-viq VJFI I PFRMITAPP <br />