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,.P4� •..A • SAN JOAQUIN COUNTY • FILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> a'' { 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> p Telephone:(209) 468-3147 Fax.(209) 468-3433 Web:www.siclov.ora/eh UNIT IV <br /> �/FOR <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 15135 Eight Mile Road Cross Street Correia Road City/State Stockton Zip 95219 APN 069-000-21 <br /> Omer <br /> A. <br /> r �.ddress <br /> Property. <br /> PReclamation District 203 421 South E1 Dorado Street Suite 6 Stockton 95203 209-966-96]5 <br /> OwneCity/State on Zip Phone <br /> All Nell Abandonment 3369 Fitzgerald Road Suite a Rancho Cordova 848359 916-363-9355 <br /> C-57 Contractor Address City/State Lic Phone <br /> Advanced Geogoviroamencal 53] Shaw Road Stockton 65022] 209-467-1006 <br /> Consultant/Sub Cntr A gess City/State LC Phone <br /> Billable Party Advanced GeoEnvironmencal me Mdress B37 Shaw Road City/State Stockton Zip 95215 Phone 209-467-1006 <br /> GIS Coordinates:Xc)sg•O(oCj Y -i l t, Y9v 3 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDS <br /> ❑WELL IDs <br /> ❑OTHER IDS <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING D HOLLOW STEM DIA.OF BOREHOLE D MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: <br /> _D EXTRACTION:Vapor/Water D HAMMER/DRN/EN CASING THICKNESS TYPE OF CASING: D STEEL D PVC ❑ OTHER <br /> _D SOIL VAPOR PROBE D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS D HOSE D PIPE <br /> _D SOIL BORING D PUSH POINT(GP/CPT) GROUT SEAL PUMPED:D Yes D No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _D INJECTION fe air sparse.Owns)D HAND AUGER GROUT SPECIFICATIONS <br /> _D OTHER: D OTHER: APPROX.BORING DEPTH D BOLTED TRAFFIC BOX OR D STOVE PIPE <br /> CONDUCTOR CASING D No D Yes:Casing Dia: Casing Depth: Bonng Dia:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK Al I THAT APPLY) <br /> _#OF WELL(S)TO BE DESTROYED p OVER-BORE DIAMETER of B" INCHES TO DEPTH OF" and '17 <br /> WELL IDS: MM-11, W-12 and W-13 ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Portland Cement (6 gallons per 94 lbs bag) ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:E AUGERS ❑O HOSE ❑r 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 Ith I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,a appy able California laws. ftRb�51�� F�3� 3 <br /> Si ned �/ l` Title/Company eroie=c aemogiac `R '4.g�ja <br /> 9 <br /> Print Name °'nie vitt°""e"a Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> 0 <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY °GD gKts avt DATE ISSUED -• —� <br /> GROUT INSPECTION BY FINAL INSPECTION BY ---tTATE H1 f 6f' <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> `jot $13Dx 3 370 // YZ2 LDouau 4(:3-YS SR# 718L7 2 <br /> RO# <br /> 3500 <br /> 29 0 50 r3 <br /> C-57 ✓ WC WAIVER PV*- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ENCROACHMENT DOC wAt- <br /> EHD 29-01 7/24/14 WELL PERMIT APP <br />