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coy ; I <br /> L <br /> l4 �7..� SAN JOAQUIN COUNTY <br /> `� ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> a ;a Telephone:(209) 468-3454 Fax:(209)468-3433 Web:www.sictov.org/eh <br /> 4 / <br /> • G%FOR 1111 r 12 <br /> WELL & BORING PERMIT APPLICATION P� <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1I YEAR FROM DATE ISSUED I e f2 <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 <br /> 235 W.Scotts Ave. Cross Street Scott Sl./Monroe St. City Stockton Zip 95203 APN /'y 7`/'Z CYO / <br /> Property San Joaquln Lumber Co. 235 W.Scotts Ave. City Stockton Zip 95203 Phone 2091!65-5651 <br /> Owner Address 8q�_ 916-363-9355 <br /> C-57 Contractor All Well Abandon Address 3369 Fitzgerald Rd.,Ste B City Rancho CordovaLk Phone <br /> A.G.E. 837 Show Rd. Stockton -680227-- 2119-067-1006 <br /> Consultant/Sub Cntr Address City LI( Phone <br /> Billable Party <br /> A.G.E. Address 837 Shaw Rd city <br /> Stockton Zlp 95215 Phone 209-467-1006 <br /> GIS Coordinates:X 32.Sq t'on v-r2'l, 514324 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELUBORING(CPT,GEOPROBE HYDROPUNCH,HAND-AUGER,OTHER) <br /> ®SOIL BORING IDs AGE-BA <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING EI HOLLOW STEM DIA.OF BOREHOLE e_❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: no <br /> _.O EXTRACTION:Vapory Water ❑HAMME IDRIVEN CASING THICKNESS no TYPE OF CASING: 0 STEEL 0 PVC ❑ OTHER no <br /> _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL no TREMIE TYPE TO BE USED: El AUGERS 0 HOSE 0 PIPE <br /> %❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:(9 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _D INJECTION n a AlrSnaroe Oxonal❑HAND AUGER GROUT SPECIFICATIONS portland type II <br /> 0 OTHER: ❑OTHER: APPROX.BORING DEPTH 100' 0 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> see EHD-approved Work Plan dated 10l15114CONDUCTOR CASING El No O Yes:Casing Dia: no Casing Depth: no Boring Dlo:no <br /> COMMENTS. <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:rcHECK ALLTHArAPPLY) <br /> _#OF WELL(S)TO aE 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 L>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> 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§,and all applicable C 'ornia laws. project Manager <br /> Signed Title/Company <br /> Print Name <br /> Timot y J ellar Date 01121/2015 <br /> _ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 3/1 U.1 Y119&1-7-01V IQ o ' <br /> WORK PLAN DATED <p C7v Butz ) �z gin14 <br /> APPLICATION ACCEPTED BY DATEISSUED I.2 'Y AREA /GQ <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RD# INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# <br /> 3701 $13z,X _ v ! loSL� �vav r- zr-lS SR# <br /> RO# <br /> 353 O 350D <br /> PR# <br /> 2900 <br /> C-57 ✓ WCy WAIVER Ph-- C57 LETTER OF AUTHORIZATION TO SIGN PERMIT /� ENCROACHMENWDO ELLPERMIT P <br /> FHn�e-al mnarro <br />