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ORIGIN!Al' <br /> oo4`'to <br /> SAN . OAQUIN COUNTY <br /> y ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.oM eh UNIT IV <br /> WELL & BORING PERMIT APPLICATION <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. 7/—:?oo-/� <br /> Site Location 2431 E Mariposa Rd Cross Street Hwy gg Stockton 95205 -r City Zip APN <br /> Property BJJ Trucking 2431 E Mariposa Rd Stockton 95205 209 466 9001 <br /> Owner 9 Address City Zip Phone <br /> C-57 Contractor Advanced Geo EnviroAddress 837 Shaw Road City Stockton Lic 680227 Phone 209 467 1006 <br /> Consultant/Sub Cntr Address City Lic Phone <br /> Billable Party Address City Zip Phone <br /> GIS Coordinates:X Y i2j 23?9 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) 131-1310 <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 2 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water O HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 20 feet TREMIE TYPE TO BE USED: IN AUGERS ❑HOSE ❑PIPE <br /> 100 SOIL BORING (Z 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 Portland <br /> O OTHER: ❑OTHER APPROX.BORING DEPTH 7n fpPt ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: <br /> Phase 11 workplan CONDUCTOR CASING O No O Yes:Casing Dia: 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 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 /> Re ulations,and all a II�' I��Californr I <br /> Si yned tC��. Title/Company Geologist/Advanced Geo Environmental <br /> Print Name William Little Date -2 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS ��"� wry 1/PGSA Q�� S IZ�l�7n�i <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY J-�t1 DATE ISS <br /> GROUT INSPECTION BY FINAL INSPECTION BY 3o�y <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 /> �pC REQUEST PR# <br /> 2 5 <br /> $125x <br /> SR# �(tU <br /> RO# <br /> 3 j (3500) <br /> PR# <br /> (2900) <br /> C-57 ✓ WC // WAIVER n)�y C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT AlikENCROACHMENT DOC <br /> EHD 29-01 01/13/12 WELL PERMIT APP <br />