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•IN SAN.1OAQUIN COUNTY <br /> COPY <br /> x �E. <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street,Stock,on, CA 95202-3029 SITE MITIGATION <br /> - Telephone:(209)468-3454 Fax:(209)4618-3433 Web:www.siuov.ortt/ehd UNIT IV <br /> WELL & BORING PERNIIT 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 pennit to construct andlor ins+all 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.mquin County Environmental Health Department. <br /> Site Location 520 N. 91 Dorado Sires Street Fremont St _ City Stockton Zip 95202 APN 139-060-32 <br /> Prope%u ene & Darlene Warne 372 S. Locan Ave Fresno 93727 <br /> all Owner 9 !Address _ City ZIP Phone <br /> Wall eaenC 45 Bea[ty rave u to A sdciaaento LIC naffs Phone 1-916-363-9355 <br /> C-57 Contractor Address City 2 <br /> Consultant(Sub �t}nce GeoEnviroaressa ' Inc. 837 Bhaw CSCocton —Dc Pnon€09-467-1006 <br /> Billable PartyBabu Sagireddy Address 801 East March La:re City Stockton Zip 95210 Phone 415-990-125 <br /> GIS Coordinates:X 3 7•q S 7 Y <br /> CONSTRUCTION WORK TO BE PERFORMED: CTI <br /> ANEW WELLIBORING(CPT,GEOPROSE,HYDROPUNCH, <br /> HAND-AUGER,OTHER) <br /> )9SOIL BORING IDs SB-1 thru SB-6 _ O <br /> 0 WELL IDs <br /> 0 OTHERIDs - <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _O MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_•_ 0 MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:VaPOd Water 0 HAMMERIDRIVEN CASING THICKNESS .,_TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER �- <br /> _O SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEP.L TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE O PIPE <br /> $$SOIL BORING XXPUSH POINT(GP(CPT) GROUT SEAL PUMPEC 0 Yea 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 NJECT(ON 0,Ar aaaaa oznnbt O HAND AUGER GROUT SPECIFICATIONS 94 LB PORTLAND + 6 GALLONS WATER <br /> l7 <br /> _0 OTHER! 0 OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING .7 No 0 Yea:Casing Dig: Casing Depth:_ Bcdng Ola:_ U <br /> COMMENTS: _ <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: O&STRUCTIOD-(cHEcic au Tr1ATAPPLrI <br /> ON METH (!' <br /> _#DF LNELL(S)TO BE DESTROYED' L]OVER-BORE DIAMETER OF_INCHES TO DEPTH OF FT 7t <br /> WELL IDs: C]PRESSURE GROUT TO DEPTH OF rT BELOW SURFACE <br /> GROUT SPECIFICATIONSC(,��EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USEO1 AUGERS El HOSE 0 PIPE I.]MUSHROOM CAP AT L3 FT) Fr 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 don-)In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations and all appllcabl ali- trite Lm <br /> Signed ��- <br /> Print Name -Date It it <br /> t- DEPARTMENT U ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS 5 Z 0 I befiw S r <br /> WORK PLAN DATED /UOL'iRr�Ee ✓y 2Jo/! <br /> APPLICATION ACCEPTED BY OIL- DATE ISSUED �' '_�__..._.AREA�G <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICON DITIONS: <br /> ACCOUNTING ONLY. AID# FAC # <br /> SERVICE RO# <br /> PE CODES FEE INFO AMT REMITTED CHECK# REGV'D BY DATE REQUEST PR# INVOICE <br /> 2 rd� <br /> $125, l SR# <br /> 33907 ;O# <br /> )-9o3 ?— 37S Lo0 <br /> C79 WC D WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PE MIT —rROACHM DOC Ufa <br />