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ORIGINAL <br /> A4`''"• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> • 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> Q�rFOR <br /> a UNIT IV <br /> Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.siclov.orglehd <br /> WELL & BORING PERMIT APPLICATION RECEIVED" <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> FEB 19 ZOiq <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 compliancewith San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health DepartmeENVIRONMENTAL HEALTH <br /> Site Location 1905 N.Broadway Ave Cross Street Waterloo Rd City/State Stockton/CA Zip 89501 APN `M3rid tl29 } ^� <br /> Propert 9706853529 <br /> Owner &op Production Services(CPS) Address 3005 Rocky Mountain Ave City/State Loveland/CO Zip 89501 Phone <br /> C-57 Contractor TEG Address 11350 Monier Park Place City/State Rancho cordova/CALiC 706568 Phone 9168538010 <br /> Consultant/Sub Cntr Rubik Environmental Address 320 Flint St City/State Reno/NV Lic Phone 7756220857 <br /> Rubik Environmental 320 Flint St Reno/NV 89501 7756220857 <br /> Billable Party Address City/State Zip Phone <br /> GIS Coordinates:X 37.981 Y-121.254 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> X NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑ SOIL BORING IDs <br /> ❑WELL IDs <br /> X OTHER IDs SV-1,SV-2,SV-3,SV-4 <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2 inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION.Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS N/'4 TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> 4 ❑' SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑SOIL BORING ❑O PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes 9 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ❑INJECTION(i e AirSoaroe ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat Cement <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 5 feet ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING 9 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 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,and all applicable California laws. / <br /> Senior Geologist/Rubik Environmental <br /> Signed Title/Company <br /> Stephen Menin er Date 02/18/2014 <br /> Print Name g <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS ' v-J �04�CEJ <br /> WORK PLAN DATEDOV 6m 4C1 ,741,4 WINVIIIIII <br /> APPLICATION ACCEPTED BY L o PVN DATE I EA,, <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE 6z <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 05 $125X l ),y7 <!00,14g2�Z '(q SR# ((,S <br /> RO# <br /> 3500 <br /> zoo <br /> C-57 _ WC _WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT t' ENCROACHMENT DOC A/ <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />