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• SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> 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 /> 801 Diamond St. E. Worth St. Stockton, Ca 155-320-21 <br /> Site Location Cross Street City/State _ APN <br /> Property BNSF Railway 740 East Carnegie Drive San Bernadino, Ca 909-386-4081 <br /> Owner Address City/State Phone <br /> C-57 Contrao Gregg Drilling Address 950 Howe Road City/State Martinez, CA Lic. 485165 Phone 925-313-5800 <br /> Consultant/Sub Cntr Kennedy/Jenks Address 303 2nd St. Ste 300 South City/State San Francisco CA 94107 415-243-2150 <br /> Billable Party Same Address City/State Zip Phone <br /> GIS Coordinates:X -121.258066 y 37.949714 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> X NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) KB-1, KB-2 <br /> X SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING X HOLLOW STEM DIA.OF BOREHOLE _7 In ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS _n/a TYPE OF CASING: ❑STEEL 0 PVC 0 OTHER <br /> _D SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 50 _TREMIE TYPE TO BE USED: ❑AUGERS D HOSE 0 PIPE <br /> 2 X SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes X No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION(I.e Air SDerOe.Ozone)0 HAND AUGER GROUT SPECIFICATIONS Neat cement <br /> _0 OTHER: D OTHER: APPROX.BORING DEPTH 50 ft. ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING X No 0 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 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(>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 /> Regulation/"nd all applicable Caallg¢ornia�laws/� / <br /> Signed y/(yil...�L/ ////!2 �'+'" Title/Company o7�a/'X <br /> Print Name / 'er lr e me-4ee ��� <br /> d Date_ 4/6U//5- <br /> I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS T01 DJ ICAr1nnN dt 5 -V t S�ri�cf b <br /> WORK PLAN DATED Z 1- / <br /> APPLICATION ACCEPTED BY LA �t AAc c r DATE ISSUED 3 Z AREA <br /> GROUT INSPECTION BY ( 'oma— FINAL INSPECTION BY DATE !$— <br /> DESTRUCTION INSPECTION BY DATE <br /> COMME NTSICON DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST I PR# <br /> 7.gbS $130x SR# <br /> RO# <br /> 3500 <br /> PR# <br /> (2900 <br /> C-57_ WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 7/24/14 WELL PERMIT APP <br />