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COPI <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> a:y. SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> •a Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.orglehd <br /> iikot+ <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 toss Street Fremont StCity Stockton Zip 95202 APN 139-060-32 <br /> Pr0art u ene & Darlene Warne 372 S. Locan Ave Fresno 93727 N/A <br /> Owner g address City Zip Phone <br /> Advanced GeoHnvironmental Inc 83] Saw Road Stoc c�on 68022] 209-967-1006 <br /> C•57 Contractor Address City Lic Phone <br /> ��Jvanced GeoEn'Iro�ental, Inc. 837 Shaw Rd ChYtockton Lic 680227 phone 209-467-1006 <br /> Consultant/Su ntr ress <br /> Billable PartyBabu Sagireddy Address 801 East March Lane City Stockton Zip 95210 Phone 415-990-0125 <br /> GIS Coordinates:X 12 958 Y :r21, 24 f <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> KXNEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> T3SOILBORINGIDS B7 & B8 (301bsg) Vl & V2 (5' bsv) - <br /> ❑WELL IDs <br /> ❑OTHER IDS <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _O EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> 4 MOIL BORING Xj PUSH POINT(GPI CPT) GROUr SEAL PUMPED:D Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _17INJECTION heAr Swroe.ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> 94 LB PORTLAND + 6 GALLONS WATER <br /> _❑OTHER: 30' and 5'❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑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:ICHECK ALL THAT APPLY) <br /> _#OF WELLS)TO BE DESTROYED ❑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(>3 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 pre ared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,an applic a"la Laws. <br /> TillelCompany president <br /> Signed12/22/11 <br /> Print Name R b c to - y / Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS 2.O C� /) ),6 srobx.) fA <br /> WORK PLAN DATED D6e6M ltla /71 <br /> APPLICATION ACCEPTED BY j YyF9-&I'1 DATE ISSUED /- 3—f/ AREA /09 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COM M ENTSICON DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE IRO# INVOICE <br /> PE CODES FFEEINFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR#IV _ SR#C7�o40 <br /> 290 3�iC57 _ .___WAIVER ___ C57 LETTER OF AUT JRI �TI�f� lGN PERMIT __ ENCROFlCHMENT DOC A/ <br />