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NOV ivORIGINAL <br /> /bPa�''y•c SAN JOAQUIN COUNTY <br /> �• ..,,,,fes••.oG <br /> ENVIRONMENTAL HEALTH DEPARTMENIIRONMENTALHEALTf LOP <br /> y 600 East Main Street, Stockton, CA 95202-3029 'ERMITISFRV!CSITE MITIGATION <br /> �.. t <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/eh UNIT Iv <br /> �4�/FOR <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 500 East Louise Aveross Street Harlan Road city Lathrop Zip 95330 APN 198-120-08 — <br /> Property PNA-Lathro 811 Madison Ave. Toledo, OH 43604 <br /> Owner p Address City Zip Phone <br /> C-57 Contractor AGE Address 837 Shaw Road cityStockton,CA Lic 680227 Phone 2094671006 <br /> Consultant/Sub Cntr Address " " City " If Lic " 11 Phone <br /> Billable Parry Reynolds/Brown Address 1200 Concord Ave city Concord, CAip 94520 Phone 9256748400 <br /> GIS Coordinates:X 3?,Boma Y (7 1 >y Suite 200 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> )MOIL BORING IDs B# to B# (approximately up to 20) <br /> ❑WELL IDS <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE2 Inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION.Vapor/Water O HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 30 ft TREMIE TYPE TO BE USED: ❑AUGERS O HOSE CK PIPE <br /> _IX SOIL BORING X PUSH POINT(GP/CPT) GROUT SEAL PUMPED: ❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(ieAir Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS POrtland <br /> O OTHER: ❑OTHER: APPROX.BORING DEPTH 30 ft ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE <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: 0 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,aqd all,a licable Cali//or laws. <br /> �� GCt <br /> Signed �� i ��� AGE <br /> ( Title/Company <br /> Print Name William Little Date 11/18/14 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS S� E• L04 r sc- r4 U6 4.6—r"RoP <br /> WORK PLAN DATED v�TOe��EQ <br /> APPLICATION ACCEPTED BY .J. /O IBiC�t m DATE IS <br /> GROUT INSPECTION BY FINAL INSPECTION BY nr. DATE/,Z4,f <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 /> 1"105 $ x (072<� �vu�vr6Q /4644 SR# 7/052- <br /> RO# <br /> (3500) <br /> PR# <br /> (2900) <br /> C-57 V WC _WAIVER IOV C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT &0-- ENCROACHMENT DOC ISA <br /> EHD 29-01 01/13/12 WELL PERMIT APP <br />