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ORIGINAL <br /> aVA IlY. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 2� <br /> <: SITE MITIGATION <br /> N` 1868 East Hazelton Avenue, Stockton,CA 95205-6232 UNIT IV <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sjcIov.orci/ehd <br /> L%FORt'� <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> Eggiman Hydraulic Garage."City of Stockton"wens 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 Irnan 2732 Belleza Drive San Diego Zi 92108 phone <br /> Owner 99 Address City Zip <br /> f`108 <br /> 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 /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDS <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING 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 7REMIE TYPE TO BE USED: ❑AUGERS ❑HOSE Cl PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(I.e.AirSoarge Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE <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 NOVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: MW-1,MW-fr MW-JMW-� X PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> 7REMIE TYPE Tq BE USED:❑ UGERS ❑HOSE Ij PIPE ❑MUSH OOM CAP (>3 FT) FT BELOW SURFACE <br /> COMMENTS L#1 4C/J21Zjlcay,0- <br /> /iyrl ,`S/'T�f(7� Llenrn,a� lArtirli Ibn 1 � <br /> 5 WORKING DAYS NOTIC REQUIRED(AFTER PERMIT ISSUANCE) FOUR INSPECTION APPOINTMENTS <br /> I hereby ce that I ha a preps is application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regutatio s, nd app ca 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 <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPB�Y <br /> Y DATE I AREA <br /> GROUT INSPECTION FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> VACCOUNTING ONLY: AID# FAC# <br /> DES FEE INFO AMT REMITTED CHECK# RECV'D BY LfR <br /> RVICE RO# INVOICE <br /> QUEST1-7 $125x 00 � / #� 0co 00r ' oo# <br /> 00 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHME— :_j <br /> NT DOC <br />