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p4uIN\\ ' <br /> SAN JOAQUIN COUNTY � � " N"A <br /> a ENVIRONMENTAL HEALTH DEPARTMENT ^LOP <br /> NH"MITIGATION <br /> ' ':• 600 East Main Street, Stockton, CA 95202-3029 %��2 <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sjcIov.oMjgLh UNIT IV <br /> �iFotiiN .:NViHoj, /IE('VTij`hl <br /> WELL & BORING PERMIT APPLICATION SER �7-�� IaALTN <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIA k- RV1rFq <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 1650 S EI Dorado St Cross Street East 3rd St City Stockton Zip 95206 APN 167-032-13 <br /> Property Edmond Pimentel 95219 209 610-1650 <br /> Owner Address 4202 Bass Road City Stockton Zip Phone <br /> C-57 Contractor Advanced GeoEnv. Address 837 Shaw Road City Stockton Lic 680227 Phone 800 511-9300 <br /> Consultant/Sub CCntr Advance'dLGeoEnv.Address 837 Shaw Road City Stockton Lic 680227 Phone 800 511-9300 <br /> Billable Party [f 'c,i v /1�P✓ iGt Address Il✓S J S vy^/( rkL(' City Zip ZJ OL Phone y 70 —;/ 5 <br /> GIS Coordinates:X 37.935605 Y -121.28482 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> SOIL BORING IDs B4 through B7 <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 ❑HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _[_I SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Entire TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE E)PIPE <br /> 4 6 SOIL BORING N 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 94 Ib portland cement and 6 gallons water <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 3 and 40 feet bsg❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING EKNo❑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 aplAable Cal"ornia laws. <br /> Signed - Title/Company Geologist <br /> Print Name Bridn Millman Date Ci <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS S, EL L�24f�d 5 �7 <br /> WORK PLAN DATED SEP74-mao ZDV 4 <br /> APPLICATION ACCEPTED BY yo •�-t DATE ISSU mmirwr &� <br /> GROUT INSPECTION BY FINAL INSPECTION BY /0- <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 /> $ x 8:1COJ 9-u-/tel SR# 7GGGZ <br /> 2c�O RO# <br /> J (3500) <br /> PR# <br /> (2900) <br /> C-57 ✓ WC _ZWAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ti ENCROACHMENT DOCS <br /> EHD 29-01 01/13/12 WELL PERMIT APP <br />