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ORIGINA ! - <br /> 0.�4`''�'•.c SAN JOAQUIN COUNTY <br /> •.tet •.o <br /> 2 rrr ? ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> N: [ <br /> •': '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sicfov.org/eh <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATRAPR 14 2014 <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 mEMR0NMEIffALhK5AffH <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health DepartmentPERMITISERVICES <br /> Site Location 1639 S Stockton Street Cross Street West 3rd Street City/State Stockton Zip 95206 APN <br /> Property <br /> Owner city of Stockton Address 925 E1 Dorado St. City/State Stockton Zip 95202 Phone 209-937-8366 <br /> C-57 Contractor National EWP Address 1961 Meeker Avenue City/State Richmond Lie 953696 Phone 510-236-6282 <br /> Consultant/Sub Cntr Geosyntec Address 3093 Gold Canal. Dr, 4201 City/State Cordova Lie Phone 916-637-8333 <br /> Billable Party John Taylor Fertilizer Address PC Box 1030 City/State Marysville Zip 95901 Phone 530-792-2539 <br /> GIS Coordinates:X -121.299817" Y 37.939089' <br /> -S 3N0 -/2/ ZCtfP <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ®NEW EL ORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> EIWELLIDs MW-12 <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 1 X❑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 SEALapprox. 75 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 Sparge,ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ®OTHER:Sonic APPROX.BORING DEPTH approx. 90 feet M 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 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 /> Signed 72_ _ Title/Company Hydrologist, Geosyntec Consultants <br /> Print Name Grant Hurst Date 9/10/2019 <br /> pp <br /> DEPARTMENT USE ONLY+J <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS U �g . !!9yT S 1—.0 She e7woll <br /> WORK PLAN DATED M vf-Q.d 2 ej /3 <br /> APPLICATION ACCEPTED BY J yb OK' "ril I DATE IS AL Kaf&A <br /> GROUT INSPECTION BY FINAL INSPECTION BY E <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 /> REQUEST PR# <br /> Z�vV $125x / UG8 �'aa�P� �-�Y-/y SR# 4451 Z <br /> RO# <br /> 2�C• ?75 3500 <br /> PR# <br /> 2900 <br /> C-57 f/ WC V WAIVER IV C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />