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SAN JOAQUIN COUNTY i <br /> a a <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> y' 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siAov.org/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/-300--13 <br /> Site Location 2431 E Mariposa Rd Cross Street Hwy 99 City Stockton Zip 95205 APN W4-030--ft- <br /> Property <br /> -036=1f- <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 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) 131-1310 <br /> ®SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2 ❑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 20 feet TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ❑PIPE <br /> 101f 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 Portland <br /> ❑OTHER ❑OTHER: APPROX.BORING DEPTH 20 fPAt ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: <br /> Phase 11 workplan CONDUCTOR CASING❑No❑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 WELLS)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,an�'ap licable Califo niaa la�nrs. <br /> Signed +�� Title/Company Geologist/Advanced Geo Environmental <br /> Print Name William Little Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS IPJ ST�L�C�y <br /> WORK PLAN DATED 14 3) <br /> APPLICATION ACCEPTED BY ,- c'/;ICU, <br /> iv DATE I EA I Ca <br /> GROUT INSPECTION BY FINAL INSPECTION BY Q ATE lz3O �y <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITI ONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> ? REQUEST /PR/# <br /> 2 �U $125x SR# �o�ttUlO <br /> RO# <br /> l (3500) <br /> PR# <br /> (2900) <br /> C-57 V WC WAIVER `U p�- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT Yvl ENCROACHMENT DOC <br /> EHD 29-01 01/13/12 WELL PERMIT APP <br />