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f1`LE COPY <br /> ,aP" a row SAN JOAQUIN COUNTY • NOV 182o <br /> ENVIRONMENTAL HEALTH DEPARTMENTnENT61 yFALTH LOP <br /> -"7 ""'SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> Telephone:(209) 468-3147 Fax: (209) 468-3433 Web:www.slaov oro/eh <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 500 East Louise Avt4loss street Harlan Road city Lathrop Zip 95330 APN 198-120-08 <br /> Property p Address <br /> Owner PNA-Lathrop 811 Madison Ave. Toledo, OH 43604 <br /> City Zip Phone <br /> C-57Contractor AGE Address 837 Shaw Road City Stockton,CA Lic 680227 Phone 2094671006 <br /> Consultant/Sub Cntr " " Address " " City " " Lic " .1 Phone " " <br /> Billable Party Reynolds/Brown Address 1200 Concord Ave city Concord. Chip 94520 Phone 9256748400 <br /> GIS Coordinates:X 37, 339 Y 'f2.1.�rZ4 Suite 200 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> $SOIL BORING IDs B# to B# (approximately up to 20) <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA OF BOREHOLE2 InCh 0 MULTIPLE CASINGS Cl MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water 0 HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL 30 ft TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE X PIPE <br /> _IX SOIL BORING X PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _OINJECTION(Le Ar Sosme 0...I Q HAND AUGER GROUT SPECIFICATIONS POrtland <br /> _0 OTHER: O OTHER: APPROX.BORING DEPTH 30 ft 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING 0 No❑Yes:Casing Dia: Casing Depth: Boring Dia:_ <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD•(CHECK ALL THAT APPLn <br /> _#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> EL <br /> WL 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,a�dpall a licable Cali or�� aws. <br /> Signed V_��f .�d�� —, TRIe/Company AGE <br /> Print Name William Little Date 11/18/14 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS SCn E• Lo 4,tSF 4 OF 4 g7wel)p <br /> WORK PLAN DATED U('T-o 862 /0 P zeo r Z/ <br /> APPLICATION ACCEPTED BY J. `�201Cu rn DATE I ' . F <br /> GROUT INSPECTION BY FINAL INSPECTION BYtA.Al DATE uY <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 /> 05 siruxt /077.1-1 SR# 7/U5Z <br /> 3500) <br /> PR# <br /> (2900 <br /> C-57 y WC _WAIVER IV 657 LETTER OF AUTHORIZATION TO SIGN PERMIT WA- ENCROACHMENT DOC !�A <br /> EHD 29-01 01/13/12 WELL PERMIT APP <br /> 4r PsacaA <br />