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FILL CU4Y <br /> • .- <br /> COP� <br /> SAN JOAQUIN COUNTY <br /> Is ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stock On, CA 95202-3029 SITE MITIGATION <br /> • p Telephone: (209) 468-3454 Fax:(209) 4 >8-3433 Web:www.sigov.org/ehd UNIT IV <br /> WELL & BORING PERn]IT 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 ins alk 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,Daquin County Environmental Health Department. <br /> Site Location 520 N. El Dorado Dross Street Fremont St qty Stockton ZIP95202 APN 139-060-32 <br /> Propertu ene & Darlene Warne 372 S. Locan Ave Fresno <br /> Owner g Nddress _ qty Zip 93727 Phone <br /> we an onement 4245 Beatty Drive nate A Sacramento a4a353 1-916-363-9355 <br /> C-57 Contractor r� Address City LID Phone <br /> ConsultanVSub Cntince GeoEnviro enta Zn� c. 837 Shaw ;a Stockton— 209-467-1006 <br /> rr�ress _ Ciry Lic Phone <br /> Billable PartyBabu Sagireddy Address 801 East March Lane Ciry Stockton Zip 95210 phone 415-990-125 <br /> GIS Coordinates:X 5 7 Y �l�l•,29/ <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> UNEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER) (Jl <br /> )OSOILBORINGIDb SB-1 thr SB-6 )Q� <br /> 0 WELL IDs O <br /> O OTHERIDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Z: <br /> _El MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE__ D MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_ n <br /> _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS - TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER r <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SE.L TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE D PIPE <br /> MOIL BORING }[a PUSH POINT(GP/CPT) GROUT SEAL PUMPEC D Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION(1 u Ozone)0 HAND AUGER GROUT SPECIFICATIO+4S 94 LB PORTLAND + 6 GALLONS WATER <br /> _0 OTHER: 0 OTHER: APPROX.BORING DEPTH5 T ❑BOLTED TRAFFIC BOX OR [I STOVE PIPE i7 <br /> COMMENTS: <br /> CONDUCTOR CASING .7 No 0 Yes:Casing Die: Casing Degh:_ Ending Dia: <br /> (� <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS kGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: cEsrRucnoN METHOD CHECK ALL THAT APPLY) <br /> #OF WELLS)TO BE DESTROYED []OVER-BORE DIAMETER OF INCHES TO DFPTH DF FT <br /> WELL IDs: <br /> GROUTS []PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> PECIFICATIONS [ <br /> TREMIE TYPE TO BE USEI EXPLOSIVES FROM TO FT BELOW SURFACE <br /> D:Q AUGERS HOSE ❑PIPE <br /> COMMENTS I3 MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT 13SUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be don t In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws, ( � <br /> Signed _ - - �_ ;__ Title/Comp:my L.l�\w ,� U,� A 9[3 m <br /> Print Name 4r2if y \CCC Date_ l ��•ZLT1\ <br /> DEPARTMENT US= ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS .5 ZO /(/• �L I�Q/9I� <br /> WORK PLAN DATED NoWnREe L, 2011 <br /> APPLICATION ACCEPTED BY _�_� OX", �f DATE ISSUED <br /> g /I AREA <br /> GROUT INSPECTION BY &a(r � y �� FINAL INSP1DATE <br /> 11146-11 <br /> DESTRUCTION INSPECTION BY ATE a.... b— <br /> COMME NTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID If FAC # _ <br /> PE CODES FEE INFO AMT9REHECK# REC V'D BY DATE EICERO# NVOICE <br /> REQUEST PR#S 125x r SR# <br /> R0#)-cf°3 ?S ooS3G7lo <br /> C-57 V WC L WAIVER C57 LETTER OFAUTHORIZA1 ON TO SIGN PERMIT z ROACHM DOC. U! <br />