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�I <br /> I - <br /> p4 SAN JOAQUIN COUNTY <br /> y :K ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> - 1868 Hazelton Avenue , Stockton , CA 95205-6232 SITE MITIGATION <br /> • rF... <br /> :r Telephone: (209 ) 468-0343 Fax: (209) 4684433 Web: www.smcehd.com UNIT IV <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> h 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 /> Joa�uignoCoun( Development Title, Chytser 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. <br /> Fo or Dorado and Fifth Streets on Dorado/Fifth Stockton, N/A <br /> Site Locatiori`Dw on Hunter Cross Street City/States "' Zip APN <br /> Property <br /> Owner City of Stockton Address North El Dorado St City/State st°° t°n• CA Zip <br /> 96202 Phone 209-937-13444 <br /> C-57 Contractor Woodward Drilling Address 650 River Road City/StateRio Vista, CA Lie 710079 Phone 707-374-4300 <br /> Inc. Stockton,Shaw Road s ee <br /> tkt9-467-1006 <br /> G Consultant/Sub Cntr <br /> Advanced Geoenvironmental B3 s <br /> Address City/StateLie Phone <br /> Billable Party ADSAddress 837 Shaw Road City/State Stockton CAZip�95215 Phone 209-467-1006 <br /> GIS Coordinates: X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> Fx1 NEW WELLIBORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) <br /> fx1 SOIL BORING IDs s and <br /> F1 WELL IDs and W-is <br /> ❑ OTHER IDs <br /> TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> =ED MONITORING O HOLLOW STEM DIA. OF BOREHOLE B D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> —D EXTRACTION: Vapor/ Water D HAMMER/DRIVEN CASINGTHICKNESS 0 . 215 TYPE OF CASING: D STEEL ® PVC ❑ OTHER <br /> _D SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL 16 , 70 and B'TREMIE TYPE TO BE USED: xD AUGERS ® HOSE © PIPE <br /> =® SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: E3 Yes D No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑ INJECTION (ie .Ar Swore ozenel D HAND AUGER GROUT SPECIFICATIONS Portland e ent C gallons per 94 lbe sank) <br /> _D OTHER: D OTHER: APPROX. BORING DEPTH 40 to ® BOLTED TRAFFIC BOX OR D STOVE PIPE <br /> COMMENTS: see attached site plan £ : boring and well lora CONDUCTOR CASING ❑ No ❑ Yes: Casing Dla: Casing Depth: Boring Dia: <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 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 prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations, an applicable California laws. <br /> Signed � -� Ti <br /> /` tle/CompanyGeologist <br /> Print NameVillo Date 05/12/2015 <br /> DEPARTMENT UUSp USE ONLY � 1 <br /> SITE MAP IN UNIT IV FILE - SITE ADDRESS 190 ) car F, l ( �Do , ; oU . <br /> WORK PLAN DATED J 23 IIr / 7 �0 <br /> DATE ISSUED -APPLICATION ACCEPTED BY Vi C� ff t d c—' <br /> v Z3— AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: Van A I / 0'r'rY 1 tPil <br /> ACCOUNTING ONLY: AID # FAC # <br /> PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SEREQUVIEST PR #CE RO # <br /> RINVOICE <br /> aqo 1 $ 130x 5 SV 1161 S ( 1 6- Jt r57� SR# 007218S <br /> — ura '105S 13ox 3 3 ' 'eD s00 G99 <br /> to4 4t! a I' (i 00) <br /> C-57 ✓ WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 7/24/14 WELL PERMIT APP <br />