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SAN JOAQUIN COUNTY ORIGINA <br /> PgU1fy <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> ili�"` ?";`• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> • c . P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:wwwsi9ov.orq/ehd UNIT IV <br /> 4�/FpiR <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. <br /> Site Location 2829 W.Washington St. Cross Street Navy Dr. City/State Stockton zip 95203 APN 14502013 <br /> Property <br /> Owner Jeff Sanguinetti Address 1150 W. Robinhood Dr.,Ste. 1-C City/State Stockton Zip 95207 Phone 209-477-0899 <br /> C-57 Contractor Enprobe Address P.O.Box 6093 City/State Oroville Lic #777007 Phone 530-589-2019 <br /> Consultant/Sub Cntr ERS Corp Address 1600 Riviera Ave Ste 310 City/State Walnut Creek Lic #879420 Phone 925-938-1600 <br /> Billable Party ERS Corp Address 1600 Riviera Ave Ste 310 City/State Walnut Creek Zip 94596 Phone 925-938-1600 <br /> GIS Coordinates:X 37.947305 Y -121.336324 <br /> 37"7N7 —12-133G73 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ®NEW <br /> (SOIL BORIING IDS G�OPRZ l S HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑WELL IDs BB 3 8844 BB <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 5 in ❑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 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> -LP9 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.AirSoarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS neat cement <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 10 ft ❑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 L3 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 a all applicable if law <br /> Signed �C L Title/Company Project Scientist,ERS Corp <br /> Print Name Leslie Shields Date July 23,2014 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS ;JEW <br /> Sin�-7�� SPT <br /> WORK PLAN DATED JoLl 9,Aj2,0(q <br /> G <br /> APPLICATION ACCEPTED BY Y0✓�-Kt.Gwx DATE Iftt! EA t�7 <br /> GROUT INSPECTION BY FINAL INSPECTION BY -----TE <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 /> C� <br /> REQUEST PR# <br /> p 0 $125 x ( 5d ZS SR# 70( 7 2 <br /> 3 00 <br /> PR# <br /> (2900 <br /> C-57 / WC V WAIVERJVd_ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT Ii ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />