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r <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> R , SITE MITIGATION <br /> � k <br /> 600 East Main Street,Stockton, CA 95202-3029 UNIT IV <br /> Telephone:(209) 468-3454 Fax:(209)468-3433 Web:www.sigov.orgLohd <br /> WELL & BORING PERMIT APPLICATION <br /> ENVIRONMENTAL NEAMWELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> PERNI[TISERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I <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 /> Stt*LoWlon205OO Ha11Y Drcrossstreet Arbor Avenue city racy__ zip, 95304 APN21216011 <br /> Proper <br /> Owner Spreckels Suctar Address P.O. Box 60 city Tracy ��++ zip 95378 Ph4209 834-7679 <br /> C�7C ctor V&W Dri1 l incl Addras!B806 link Crppk T)&ItlRtnr! J-- S7Lid79.nQ04 Phorle209) 469-7700 <br /> Consults ubCntr �ddresa 171 4 Ma i n ct. C)ty sci-r, Gn UCP-GA41 4 Phor(e209 838-9888 <br /> Billable Party Address City zip Phone <br /> GIB Coordinates:X 3 7 4 6 ' 17_-_3.5"N _ i� �,21s 2 6 r 3 �i_V,1i w <br /> 20MUMN MM TO nE PERFORMED, <br /> EW WELLJBORING(GPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING I-- <br /> ®WELL IDs_ <br /> ❑OTHER IDs i. <br /> TYPE 8#OF WELLIBORING INSTALLATION'TYPE CONSTRUCTION 12ECIFI0110M <br /> } <br /> L12 MONITORING Q[HOLLOW STEM DIA.OF BOREHOLE 81, ❑MULTIPLE CASINGS❑MULTI LEVEL WELL CASING DIA: <br /> r <br /> _Q EXTRACTION:Vapor/Wster ❑ ia HAMMERIDRIVEN CASING THICKNESS 2'! el _ and _a n TYPE OF CASING: E3STEEL DHVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Q f eA t TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE PIPE <br /> —❑SOtL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes [RNO(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER; ❑OTHER: APPROX.BORING DEPTH 20 IFAAt :p BOLTED TRAFFIC,BOX OR []STOVEPIPE <br /> CONDUCTOR CASING No❑Yes:Casing Me: Casing Depth: Boring DIa- <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> F MED: DESTRUCTION Nlin :(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL[Ds: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO o FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED; AUGERS ❑HOSE PIPE ❑MUSHROOM CAP AT(?3 FT) + FT BELOW SURFACE <br /> C049MENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby certify have prn <br /> spad this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Ra9ulatlons,and all to California laws. <br /> Signed T)tle/Company Geologist/Ground Zero Analysis, Inc. <br /> Print Name ,F.r i,r;;,.T._ P r i C e _ _Data Z o Z l L 1 <br /> DEP ENT USE ONLY r� < <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS O. r y <br /> WORK PLAN DATED LJ <br /> APPLICATION ACCEPTED BY DATE ISSUED Ll AREA. <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDMONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE ; ROS INVOICE <br /> REQUEST PRO 1 <br /> 3501 si22x SR# 6l29a + <br /> L!ko <br /> `3 fob M .� 35500 0111L: 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EH0 29-01 07/28/10 WELLPERMIT APP <br /> I <br /> n <br />