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-D E COPY <br /> W <br /> Pq I� SAN JOAQUIN COUNTY NOV 18 2014 <br /> N �K ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> V SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029' UNIT IV <br /> Telephone:(209) 468-3147 Fax:'(209) 468-3433 Web:www.soclov.orn/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 Constmd 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 Av&Oss Street Harlan Road City Lathrop Zip 95330 APN 198-120-09 <br /> mer <br /> OPNA-Lathrop 811 Madison Ave. Toledo OH 43604 <br /> Owner p Address City � Zip Phone <br /> C-57Contractor AGE Address 837 Shaw Road cityStockton,CA Lic 680227 Phone 2094671006 <br /> Consultant/Sub Cntr " " AddressCity" 1. " " " ° <br /> Lic Phone <br /> Billable Party Reynolds/Brown Address 1200 Concord Ave city Concord. CAip 94520 Phone 9256748400 <br /> GIS Coordinates:X 32- 6K) Y �)at- A< 1 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 D HOLLOW STEM DIA.OF BOREHOLE2 InCh D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> _O EXTRACTION:Vapor/Water D HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _D SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 30 ft TREMIE TYPE TO BE USED: ❑AUGERS D HOSE X PIPE <br /> _[X SOIL BORING X PUSH POINT(GP/CPT) GROUT SEAL PUMPED:D Yes D No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —0INJECTION(ieA,so,..Own.IDHAND AUGER GROUT SPECIFICATIONS POrtland <br /> —D OTHER: D OTHER: APPROX.BORING DEPTH 30 ft D BOLTED TRAFFIC BOX OR D STOVE PIPE <br /> CONDUCTOR CASING O 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 /> _#OF WELLS)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(>3 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, ,a�II/dP li ble_California laws <br /> Signed Title/Company AGE <br /> Print Name William Little Date 11/18/14 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS _jCr-) C 466[ ISE Ay6, L,ro7v7,/2cP s <br /> WORK PLAN DATED O(27ba Fe /O /Y <br /> APPLICATION ACCEPTED BY L K n g K"u ni DATE I FEW /G� <br /> GROUT INSPECTION BY FINAL INSPECTION BY TE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> a 40 $ 130 sR# 7/053 <br /> RO# <br /> (3500) <br /> PR# <br /> (2900) <br /> C-57 ✓ WC i WAIVER Ala: C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT NN ENCROACHMENT DOCS <br /> EH0 29-01 01/13/12 WELL PERMIT APP <br /> 3.fQK �BRC6L <br />