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0 SAN JOAQUIN COUNTY r ORIGINAL <br /> L' '• ENVIRONMENTAL HEALTH DEPARTMENT I LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 I I <br /> Telephone: (209)468-3147 Fax:(209) 4683433 Web:www.siaov.ornlehd SEP 10 2014 <br /> Ci' • <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND RCNMENTALHEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERM17/SEAY th San <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 corn <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin CountyEnvironmentalentall Health DeA 95 7 6 partment. <br /> 2S5-100-04 <br /> 1600 Durham Ferry Rd. Hl. hWa 33 Ci Zip APN � <br /> Site Location Cross Street g y ty/Slate 6 <br /> PropertSheldon Teranishi 1600 Durham Ferrycity/Slate Tracy, ZpCA95376 phone <br /> Owner Address Duck creek r Stkn C1IIic720904 Phone 209-469-7700 <br /> C-57 Contractor V&W Drilling Address City/State 209-522-4119 <br /> 1172 Kansas Ave City/State Mo estCLIcCA Phone <br /> Consultant/Sub Cntr GZA Address <br /> Sheldon Teranishi Address <br /> 1x00 Durham Ferry Rd City/Slate Trac Zip95376 Phon�09-835-3596 <br /> Billable Party <br /> GIS Coordinates:X 32,4671 Y ^12f-3262?.CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GFl]PROBE,HYDBOPUNCH_tJAN�AUGER,OTHER) <br /> gg SOIL BORING IDs �5ttS5 ..ii �S ttSS 44 SSttSs <br /> �jWELLIDs VEW- VE -4 VEW-5 VE -6 <br /> OTHER IDs See attached table <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS[ MULTI-LEVEL WELL CASING DIA: <br /> 4 TYPE OF CASING: I]STEEL ❑PVC ❑ OTHER <br /> —�EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [3 AUGERS ❑HOSE [3 PIPE <br /> -_I$SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> 15 a Ozone/❑HAND AUGER GROUT SPECIFICATIONS <br /> INJECTION!'_ e r [3 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> ❑OTHER: [IOTHER: APPROX.BORING DEPTH <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth:_ Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE <br /> a <br /> ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> able TD <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 /> ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> WELL IDS: ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> GROUT SPECIFICATIONS MUSHROOM CAP A7(>3 FT) FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑ <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations and lap ' able California laws. Agent / Ground Zero Analysis, Inc. <br /> Title/Company <br /> Signed � � -1 <br /> PrintName <br /> Eric Price Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS ,�aC.l7 y-+�t kf�/�sT rer <br /> WORK PLAN DATED 'Z ' 1 <br /> DATE ISSUED T-f�' 1G( AREA rr,9 <br /> APPLICATION ACCEPTED BY �I �D/I'Ku wl DATE <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC If <br /> SERVICE RO# INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# <br /> 3 o SAX s 2 QoGrVme -1o'1 SR# ?C:) SAI <br /> Z503 0 3 39 PR#Ron A <br /> �z� <br /> $ rj 130 2900 SROb7D5 <br /> C-57 _ Wy �CAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT tr ENCROACHMENW DOC� PERMIT APP <br /> EHD 29-01 5/09/12 IT AP <br />