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SAN JOAQUIN COUNTY IvIECEIVEOR •., n J <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP -TT AL <br /> .y <br /> ` UL 2 9 2014 SITE MITIGATION <br /> •` 1868 Hazelton Avenue, Stockton, CA 95205-623 <br /> •. :P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: f ov�.or /ehd UNIT IV <br /> � NIE ALHEALTH <br /> or,st-t>- WELL & BORING PERMIT APPLICA IT/SERVICES <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 /> E. Castle & W. Adams Sts E1 DSt. Stkn, CA 95204 City Prop <br /> Site Location Cross Street N. Dorado City/State Zip APN <br /> PropertSteve Valentine 201 Marc Ave Stkn, CA 95207 209-609- 42 <br /> Owner Address City/State Zip Phone <br /> C-57Contractor V&W Drilling Address Duck Creek rCity/State Stkn Cl�ic720904 Phone 209-469-7700 <br /> 5201 Woodmere Dr Bakersfield CA 722327 661-834-8100 <br /> Consultant/Sub Cntr Welenco Address City/State Lic Phone <br /> Billable Party Steve ValentineAddress201 Marc Ave City/State Stkn Chp 95207 Phone209-609-7842 <br /> GIS Coordinates:X —/ZL X%8& <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑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 /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.Air Soarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <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 DES ROYED ®OVER-BORE DIAMETER OF INCHES TO DEPTH OF 9 0 FT <br /> WELLIDs: See attacl list ,vo A5Gl M'&'r7tC PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONSEXPLOSIVES FROM 9 0 TO20 FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERS HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS Note. V&W will do groutina on the 4 CMT wells. Welenco will Ferform exnlo.iv demo on 3 CMT well.- <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify!Wt I have prepared Ihis application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,an II pl' abl i nia laws. <br /> Signed Title/Company Agent / Ground Zero Analysis, Inc. <br /> Print Name Rayno d Kablanow Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED 1 Ulu/Z4 <br /> APPLICATION ACCEPTED BY DATE I _Pt A to 9 9 <br /> GROUT INSPECTION BY FINAL INSPFCTION.BY,s"r ' �; '—_DATEl( L /(e�//l <br /> DESTRUCTION INSPECTION BY — DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> C REQUEST PR# <br /> SU2 $125x z,3yg4 Llot:c,&!Zk SR# �Z <br /> 33 3�S Roo) <br /> PR# <br /> 2900) <br /> C-57 1/ WC V WAIVER -57 LETTER OF AUTHORIZATION TO SIGN PERMIT 1/ ENCROACHMENT DOC_ <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />