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i <br /> f nE EIVED i LD f <br /> SAN JOAQUIN COUNTY <br /> �• YO <br /> ENVIRONMENTAL HEALTH DEPART O ENTOAL 'LOP <br /> • Stockton, CA 9` 6EPAffTI+R ITE MITIGATION <br /> 1868 East.Hazelton Avenue, i <br /> Telephone:(209)468-345t Fax.'(209)4683433 Web www.s' ov.or 1ehd UNIT IV' <br /> WELL & BORING PERMIT APPLICATION. <br /> FOR WELLS AND BORINGS.USED FOR CONTAMINANT INVESTIGATI0 SAND-RE tbiA-nok <br /> NON-REFUNDABLE PERMIT EXPIRES 1 R. OM DATE ISSUED <br /> ;Application is hereby made to San Joaquin County for a permit to constnrd.andlor.instalf the Work described. This.applicatign.is made. compliance with San <br /> ,Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department- <br /> lssaa elittm Court Rasa 7lracy.Eoulevesd Stockton 95206 �N 1e9-040-12 <br /> Site Lc'Cation Cross Street- C{ty <br /> Property 209-043-2079 <br /> ;Owner main Seann corp. A[tdress 2934 tanlcegate.nrive Crhr. Merced Zip g53ao Phone <br /> A11 Mail Abandonment - 5295 Beatty Drive Supe A - sac[amento LIL• X848359 PtlGRB 916-3fi3-9]55 <br /> C=57 Contractor Address City. . <br /> Advanced ceoEnvirenneot" Ioe. 037 Shaw Read stodktoa. ""127 209-437-k006 <br /> ConsultantfSub Cntr Address cry- Lic Phone <br /> Billable Party. Sandi Saraie Address 'Pis. box 5064. City Stocktan `Tip,,53206Phone 209-917-2079. <br /> GIS Coordinates:X Y <br />` CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GEOPROBI_HYORDPU.NCH,HAND=AUGER;OTHER):' <br /> ❑SOIL BORING IDS <br /> ❑WELL IDA <br /> ❑OTHER IDS <br /> TYPE&#OF WELLIBORING INSTALLATION.TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOWSTEM' DA OFBOREHOLE ❑MULTIPLE CASINGS[]MULTI-LEVELWELLCASING DIA:, <br /> _Ci EXTRACTION:Vapor/Water ©HAMMERIDRNEN CASiNG THICKNESS 'TYPE OF-CASING: ❑STEEL 0 PVC ❑ OTHER . <br /> _O SOIL VAPOR PROBE im at p MUD R&ARY DEPTH OF GROUT SEAL TREMIE'TYPE TO BE USED: 0 AUGERS 0 HOSED PIPE <br /> __[3 SOIL BORING(B's) 9 PUSH POINT(GPI CPT) GROUT SEAL PUMPED!0 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT). <br /> _0INJECTION(1.e.Ak,%arga.0aone)0HAND AUGER GROUT SPECIFICATIONS <br /> —0 OTHER: ❑OTHER' APPROX BORING DEPTH _ 0'BOLTED TRAFFIC BOX OR 0 STOVEPIPE <br /> CONDUCTOR CA$ING❑No'0 Yes:'Casing Dla: Casfng©epth: BoringDIa:.. <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> ;DESTRUCTION WORK TO BE PERFORMED:' DESTRUCTION METHOD:(CHECK ALL THATAPPLYI: <br /> 11 #OF 1NELL(S)TO BE .DESTROYEDE1 OVER-BORE DAMETER OF W INCHES TO DEPTH OF 27 to 56 Fr. <br /> WELL IDS: MW-1 tfirough My4-11 <br /> GROUT SPECiFtCATtONS ❑PRESSURE'GROUT To DEPTH OF FT BELOW SURFACE <br /> ❑EXPLOSNES FROM TO FT;BELOW SURFACE <br /> TREMIE TYPE TO BtUSED: AUGERS p HOSE.E)PIPE [IMUSHROOM CAP AT 3 <br /> COMMENTS See EHD epprovB letter dating O6 eceWxr 13 Fr B€LOwSt1RFACE <br /> S WORKING DAYS NOTICE,REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify That I have prepared this application.and that the work WI1 be dime in.accordarieg with San Joaquin Countysgrdfnances,Rules and <br /> !Regulations,and a pflcabf lifomia Laws. <br /> Signed TiEIe/Company Frol ect cenloyiat <br /> Print Name act Vil3acgeva Date 12/10/2023 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS 00 <br /> WORK PLAN DATED C3n2 0& . 7 3 <br /> APPi.iCAT10NACCEPTED i3Y . ._. .✓� a r�Kun-t _ DATE.ISSUED _li �lZ-'f3 AREA <br /> GROUT INSPECTION 13Y FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECITON BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: Alp# FAC# <br /> PE CODES 1 FEE INFO AMT REMITTED CHECK#. RECV'D SERVICE RO#BY, DATE REQUEST PR# INVOICE <br /> 35�Z $1z5x !i SR# (g6s <br /> r3103 576- RO 9 <br /> X500 <br /> PR.# <br /> _Ltz9OO <br /> C57 Z, WC t-' _WAIVER_ :C57 LETTER OF AUTHORi7AT10N.TO.SIGN PERMIT !/ ENCROACHMENT DOC <br />