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(PAYMENT l� RIGINAL <br /> y : iECEIVED <br /> hg�Utc 11 2413 <br /> H SAN JOAQUIN COUNTY <br /> k: •Fo <br /> AQUIN Comm <br /> I <br /> ENVIRONMENTAL HEALTH DEPARTwIROMENTAL LOP <br /> 1868 East Hazelton Avenue, Stockton, CA 9%IWNM:PF-PARTMF..I ITE MITIGATION <br /> • .._�,1.•;}. Telephone:(209) 468-3454 Fax: (209) 468-3433 Web:vvWW.sigov.orglehd UNIT IV <br /> [Ij`pR� <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> I 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 L.o}c��ation 16500 Clifton Cavrt Road Cross Street Tracy Boulevard Bay stockton Zip 95206 APN 189-040-11 <br /> Property �`! 209-943-2079 <br /> Owner Main Scone corp. Address 2930 Whitegate Orive City Merced Zip 95340 Phone <br /> All Well Abandonment 9295Heatty Drive Suite n -- Sacramento �: 848359 916-363-9355 <br /> C-57 Contractor Address City Lid Phone <br /> Advanced'GeoEnvironmental 1nc. 209-467-1006 <br /> ConSultantlSub Cntr Address e37 shave Road City Stockton T LIC 6e0227 phone <br /> Billable Party Sandi sarale Address P.G. Be. 5065 City Stockton Zip 95206 Phone 209-943-2079 <br /> GIS Coordinates:X 37-4W183 <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 ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE (svi,e ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ^❑SOIL BORING(a IS) O PUSH POINT(GP!CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e_Air Soame.Ozme)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <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 /> 11 #OF WELL(S)TO BE DESTROYED EI OVER-BORE DIAMETER OF 8" INCHES TO DEPTH OF 21 to 56 FT <br /> WELL IDS: MWA through MW-11 <br /> ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:Cj AUGERS D HOSE 0 PIPE ❑MUSHROOM CAP AT L>3 FT) FT BELOW SURFACE <br /> COMMENTS See EHD approval letter dating 06 December 2013 <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 plicabte alifomia Laws. t <br /> Signed �-�.� Title/Company Project ceologlst. <br /> Print Name �atf.1 Villanueva Date 12/10/2013 <br /> `DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS�7-dD 4tt�TAIJ <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY �f•of 0_e 01 DAEA <br /> GROUT INSPECTION BY T FINAL INSPECTION BY ATE 1 r7•Al <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: A # FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 3.50 2 $125 X 3 (d• << SR# (.E60 <br /> 3io3 f _ RO# - <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 WCy WAIVER N C57 LETTER OF AUTHORIZATION TO SIGN PERMIT !/ ENCROACHMENT DOC <br /> i <br /> ( <br />