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0 <br /> SAN JOAQUIN COUNTY I A <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> UNIT IV <br /> --. Telephone: (209)468-3454 Fax: (209)468-3433 Web:www.sigov.orclleh <br /> 9LrFORa` <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 235 W. Scotts Ave. Cross Street Scott Sl./Monroe St. City Stockton Zip 95203 APN /Y 7—/z 4o�j <br /> Property San Joaquin Lumber Co. 209-465-5651 <br /> q 235 W.Scotts Ave. Stockton 95203 <br /> Owner Address Ciry Zip Phone <br /> C-57 Contractor All Well Abandon Address 3369 Fitzgerald Rd.,Ste B City Rancho Cordovic 848359 Phone 916-363-9355 <br /> Consultant/Sub Cntr A.G.E. Address 837 Shaw Rd. City Stockton Lic-681522T—Phone 209-467-1006 <br /> Billable Party A.G.E. Address 837 Shaw Rd City Stockton ZIP 95215 Phone 209-467-1006 <br /> GIS Coordinates:X 32,54 (,05 Y-12 f. A t 923 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELUBORING(CPT,GEOPROBE HYDROPUNCH,HAND-AUGER,OTHER) <br /> ®SOIL BORING IDs AGE-BJ <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE 8#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING EI HOLLOW STEM DIA.OF BOREHOLE 81. D MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: na <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS na TYPE OF CASING: ❑STEEL O PVC ❑ OTHER na <br /> _I]SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL na TREMIE TYPE TO BE USED: E7 AUGERS ❑HOSE ❑PIPE <br /> X ❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:VI Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION 1'a AirSparae.Oz.M ❑HAND AUGER GROUT SPECIFICATIONS Portland type II <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 10()' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> see EHD-approved Work Plan dated 10/15/14 CONDUCTOR CASING LI No C1 Yes:Casing Dia: na Casing Depth: ❑a Boring Dia ❑a <br /> COMMENTS. <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALLTHATAPPLY) <br /> #OF WELLS)TO BE DESTROYED E]OVER-BOREDIAMETER OF INCHES TO DEPTH OF FT <br /> W—ELL 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 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 /> Regulation nd all applicable C forma laws. <br /> 9 �' Project Manager <br /> Signed ! rM.�1 ^ �-'"- TiOe/Company <br /> Print Name <br /> Timot yJ. ellar Date 01121/2015 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 3/5 W H9 2.64,701 j (1E (704) <br /> WORK PLAN DATED oetvFw t s /y' - <br /> APPLICATION ACCEPTED BY �Owr"7 DATE ° ' - a� . REA /�Y <br /> GROUT INSPECTION BY FINAL INSPECTION BYTE <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 /> RO# <br /> 3soj 3500 <br /> PR# <br /> 2900 <br /> C-57 WC t-� WAIVER Pill— C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT 11� ENCROACHMENT DOGMA <br /> FHn 9A-01 07/28MO WELL PERMITAPP <br />