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III Cr-:W , ORIGINAL <br /> SAN JOAQUIN COUNTY JUL 3 0 2014 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> 1868 Hazelton Avenue, Stockton, CA 9MNWNTALHEALTWITE MITIGATION <br /> °o F �:• iP Telephone:(209)468-3147 Fax:(209)468-3433 Web. ipI!aiilifh�'d UNIT IV <br /> WELL & BORING PERMIT APPLICATION T <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDAULE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permi(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 Hem,l��l��Department. <br /> Site Location 7675 W.11th Street Cross Street Poplar City/State Tracy,CA Zip9'�'y APN 250-140-12 <br /> Properly Yvonne Miller <br /> Owner Address P.Q.Box 366 City/Slate Tracey,CA Zip 95378 Phone 209.835-3466 <br /> C-57 Contractor Greg Drilling _ Address 950 Howe Ave. City/Stale Martinez,CA Lic_`185165 Phone,11?,S•-313.Ss Z <br /> Consultant/Sub Cntr CardnD Address 1117 Lone Palm Ave.,Suite 2018 Clty/State Modesto,CA Lic 95351 Phone-209.579.2221 <br /> Billable Party Cardno for Yvonne Miller Address 1117 Lone Palm Ave.,Suite 2016 City/State Modesto,CA Zip 95361 Phone 209.579.2221 <br /> GIS coordinates:x 37.740 Y-129.400 <br /> 37•���a '� —r 2J �ix�3y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLISORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> —0 MONITORING [I HOLLOW STEM DIA.OF BOREHOLE O MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _O EXTRACTION:Vapor]Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL❑PVC 0 OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED; []AUGERS O HOSE O PIPE <br /> •_❑SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION tLe-Nf Spam-,Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Din: Casing Depth: Boring Dia: <br /> COMMENTS:Gemanskirt surrounding well hox will he ren►aced <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: D STRUCTION METHOD: H APPLY)P v <br /> H ❑OVER-BORE DIAMETER OF NCHESTO D <br /> EPTH OF 20-27 FT <br /> : � -92 SAS-2. DP 1-3 FTBELOWSURFACEwELL ID.— <br /> [I PRESSURE GROUT To DEPTH Or� <br /> GROUT SPECIFICATIONS [IEXPLOSIVES FROM 70 FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:D AUGERS M HOSE 0 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 1 ha v prepared this applicatia and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all ap cable C lifo ala <br /> Signed r! Tille/Company Staff/Cardno <br /> Print Name Charlie Selkow Dated <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 7625- [� /f N S7" <br /> t WORK PLAN DATED j(A1 N 12.014 <br /> APPLICATION ACCEPTED BY DATEISSUED�' �f �l AREA f(y 'f <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICO NDITIONS: <br /> ACCOUNTING,ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED C)IECK# RECV'D BY DATE SERVICE RO it INVOICE <br /> REQUEST PR# <br /> 3SD 2 <br /> $ x Y03 0,urvTz-,p_ 2-3,z,- U SRff ?D 2,8 <br /> RO# <br /> 3s��j 3qp 3soo <br /> PR# <br /> 2900 <br /> C-571�-_ WC V WAIVER J4--* C-57 LETTER OF AUTFIORIZATION TO SIGN PERMIT - ENCROACHMENT DOC <br /> EHO 29-01 5/09112 WELL PERMIT APP <br /> I <br />