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otqu rN.,.� <br /> SAN JOAQUfN COUNTY <br /> �•'- -'�cJ"- - <br /> a:: ' ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stockton, CA 95202-3029SITE MITIGATION <br /> Telephone: UNIT IV <br /> hi 65 ,.; A one: (209) 468-3454 Fax:(209)468-3433 Web:wWwsiaov.orplehd <br /> WELL & BORINQ PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REM1=t7R <br /> 171 9EIVED <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED % 1 ' n <br /> Application is hereby made to San Joaquin County for a permit to construct and/or instail the work described. This application is made i v o�in ianD Frith San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 1469 East Hammer Ln cross street: West Lane �11M�R0�MA LTM <br /> Property City StOCktOn, Zip 9521 ' <br /> Owner: PC&F Address P.O. Box 1110 <br /> City Stockton Zip 95201 Phone 925 884-0840 <br /> C-57 Contractor Greg Driliin Address 950 Howe Road City Martinez Lic 4851$5 Phone 925 3i3-5800 <br /> Consultantl5ub cntr Delta Consultants gddress 11050 Whrte Rock Rd Ste 110 city Rancho Cordova Lic <br /> Billable Party <br /> Delta Consultants 11050 White Rock Rd, Ste 110 Phone 8DD 477 7411 <br /> Address City Rancho Cordova Zip 95670 Pnone 800 477-7411 <br /> GIS Coordinates.'X 121 17,4227 Y <br /> -33 Qjj <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> M NEW WELL/BORING(CPT,GEOPROBE;HYDROPUNCH;HAND-AUGER,OTHER) <br /> M SOIL BORING IDS CPT-1 <br /> WELL IDS <br /> EI OTHER IDs <br /> TYPE&.#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE ❑MULTIPLE CAS(NGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING ❑STEEL 0 PVC ❑ 'OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO 8E USED, ❑AUGERS ❑HOSE ❑PIPE <br /> _®SOIL BORING ®PUSH POINT(GPI CPT) GROUT SEAL PUMPED:t$I Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.Air Sparge Ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat Cement <br /> _❑OTHER: ❑OTHER: APPROXI 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 GROUTTO 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 /> 1 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 applicable CaLifornia laws. <br /> Signed TitlelCompany Delta Consultants <br /> ot <br /> Print Name 7 Date 1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE!-SIT ADDRESS b. • 6, <br /> WORK PLAN DATED <br /> APPL[CAT[ON ACCEPTED BY DATEISSUED Ii�Wio AREA 7, <br /> GROUT INSPECTION BY FINAL INSPECTION BY'/4_ DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFH <br /> O AMT REMITTED CECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR* <br /> 3 T05 5 122 x 12-7-- 7'r SR#Dok'17 f 1 <br /> 3 563 �- 3 C.6- C-d !G r z -5 !o� 3 o0 b�� <br /> PR# <br /> L2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 WELL PERMIT APP <br />