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O��OtM C <br /> SAN JOAQUIN COUNTY <br /> �,■ , X ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> Telephone; { UNIT IV <br /> `` �,Fa �►�� p {209) 468-3454 Fax. 209) 468-3433 Web:wwws' ov.or lehd <br /> WELL & BORING PERMIT APPLICATION �VG�IVED <br /> i <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATA ISSUED NOV 1.6 2010 <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 Dep <br /> Site Location 1505 East Hammer Ln Cross Street West Lane VRONMENTAL HEALTH <br /> Property City Stockton zip 95210 NPAW ` ES <br /> owner. Minor Joaquin Building CorpAddress P.O. Box 1110 <br /> City Stockton Zip 95201 <br /> Phone <br /> C-57 Cora�ractor GreggDrilling Address 950 Howe Road City Marfiriez Lic 485165 Phone 925 313-5800 <br /> Consultanhub;Cntr Delta Consultants Address 11050 White Rock Rd Ste 110 City Rancho Cordova Lic Phone 800 477-7411 . <br /> Billable.Party Delta Consultants Address 11050 White Rock Rd,Ste 110 City Rancho Cordova zip 95670 Phone 800 477-7411 <br /> GIS Coordinates:X J2 - 17 40.Z Y <br /> —33 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ®NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) l <br /> ®SOIL BORING IDs CPT-2 <br /> ❑WELL Ids , <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS" p <br /> _❑MONITORING ©HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING-pik <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL CI PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS [I HOSE ❑PIPE <br /> _9)SOIL BORING M PUSH-POINT(GP/CPT) GROUT SEAL PUMPED:®Yes'E]No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i-e Air sparge.ozone}❑HAND•AUGER GROUT SPECIFICATIONS bleat Cement <br /> _❑OTHER: ❑OTHER_ . APPROX.BORING DEPTH 120 feet ` ❑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 I <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE y <br /> TREMIE TYPE TO BE USED:❑AUGERS-,❑HOSE ❑PIPE ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE r <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 a applicable Califor laws. <br /> Signed ` Title/Company Delta Consultants <br /> Print Name Date. /. <br /> DEPARTMENT USE ONLY r <br /> SITE MAP IN UNIT IV FILE-SITV ADDRESS A(6 LN <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED 8Y C��"'"r` -DATE I 5 D 1 LO AREA <br /> GROUT-INSPECTION BY FINAL tNSPECTION BY DATE �b 1 <br /> DESTRUCTION INSPECTION BY .DATE <br /> COMMENTSICONDITIONS- <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK#. RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR'# <br /> $ 122. E d to SR#00 /u?t7-- <br /> 3Sp� 3[ La" �j(o{d CG h it$ RIX t'� 10 s oo <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57.LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07128710 WELL PERMIT APP <br />