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�� tio13 ORIGINAL. <br /> oe•A�'ty c cJ�Q SAN JOAQUIN COUNTY <br /> �.• . � •.o <br /> �VNMENTAL HEALTH DEPARTMENT LOP <br /> c• •za <br /> ►` ONM� SITE MITIGATION <br /> Fl ;E 68 East Hazelton Avenue, Stockton,CA 95205-6232 UNIT IV <br /> • •.- :` 0% ne:(209)468-3454 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> Eggiman Hydraulic Garage-On-site 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 1112 East Harding Way Cross Street North Union City Stockton Zip 95205 APN 151-02-101 <br /> Property Robert E Iman 2732 Belleza Drive San Diego 92108 <br /> Owner 9g Address City g Zip Phone <br /> C-57 Contractor Cascade Drilling Address 3000 Duluth St City West Sacramento Lic 938110 Phone 916-638-1169 ` <br /> Consultant/Sub Cntr None Address City Lic Phone <br /> Billable Party NA Address City Zip Phone <br /> GIS Coordinates:X Y <br /> i <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs I <br /> ❑OTHER IDs I <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(ie.Air Soarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: i <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS I <br /> STRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> IV #OF WELLj(�s�•'TO DE ROY s/ I ,� X OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs:MWT MW MW M 4 MW10 091 O�OS3 OS4 Oe <br /> ❑i PRESSURE GROUT To DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS fyA N o I ❑EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE Tp,BE USED AUGEF� ❑�j�O.�S.E [�PIPE ❑MUSHROOM�AP (>3 FT) FT BELOW SURFACE <br /> COMMENTS I4 Arofukace WC►Gt [75rst` nM/�vgod IdAtkA6�14441 <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby cert)Mthat I have rRepatfied this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulation d a♦I apptic i California Laws. <br /> Signed ` Title/Company General Manager/Cascade Drilling, L.P. <br /> Print Name Paul Snelgrove Date 08/30/13 <br /> DEPARTMENT USE ONLY �J <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS /��� �� /Y li i��GZ f1�Y7,( <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED Y DATE I /// <br /> GROUT INSPECTION BY FINAL INSPECTION B Sl1M� <br /> DESTRUCTION INSPECTIOXB ,yam DATE <br /> COMMENTS/CONDITIONS: /� ��/�/i 0�3� /I7if✓ �U�� �� <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> $125 <br /> O 7<00 «.� s 00 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />