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ILI <br /> SAN JOAQUIN COUNTY V <br /> a T••.o <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> Q: <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> UNIT IV <br /> 4..:,••:;;:;a Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sogov.org/ehd <br /> tlFoat' <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 520 N. El Dorado gloss Street Fremont St City Stockton Zip 95202 APN 139-060-32 <br /> Propert'ugene & Darlene Warne 372 S. Locan Ave Fresno 93727 N/A <br /> owner <br /> Ownaddress City Zip Phone <br /> Advanced GeoEnvironmental Inc 837 Straw Road Stockton 680227 209-467-1006 <br /> C-57 Contractor r7 Address City Lic Phone <br /> ConsultantlSub Cntanced GecEnviro Dress al, Inc. 837 Shaw Rd CitStockton LiG 680227 phone 209-467-1006 <br /> Billable PartyBabu Sagireddy Address 801 East March Lane City Stockton Zip 95210 Phone415-990-0125 <br /> GIS Coordinates:X 37 918 Y--('2(. 2g I <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> )INEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> BSOIL BORING IDs B7 & B8 (301bsg) Vl & V2 (5' bsq) <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _p❑V SOIL VAPOR PROBE [I MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> a XKSOIL BORING )($PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION(I. A'r Soaroe Ozone)❑HAND AUGER GROUT SPECIFICATIONS 94 LB PORTLAND + 6 GALLONS WATER <br /> ❑OTHER: ❑OTHER: APPROX,BORING DEPTH 3 0' and 5 ' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING[INo❑Yes:Casing Dia: Casing Depth: Boring Dia:_ <br /> COMMENTS: See attached work plan and site plan. <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 Cl 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 L3 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,an applic Laws. <br /> Signed lfe <br /> _Title/Company Piesidenc <br /> Print NameKit <br /> R bent M y V Date 12/22/11 <br /> r DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS 5 ZO k) C(- DOPAD6 ST S7�<rogJCpA <br /> WORK PLAN DATED T—.)6Cim <br /> APPLICATION ACCEPTED BY ,J Yo L9- h DATE AREA /1199 <br /> GROUT INSPECTION BY FINAL INSPECTION BY'-*9?- SATE 1-57- I <br /> DESTRUCTION INSPECTION BY DATE /•�� JJ <br /> C OMM ENTSICO N D ITION S: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 10,5 $125 x t SR#06'1 <br /> 03 (3560 <br /> z 00) o53i�i�� <br /> ENCROACHMENT DOC_ <br /> C-57 WC . _WAIVER ___ C57 LETTER OF AUT TMATI�4 OgGN PERMIT ✓ �l__ <br />