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ORIGINAL <br /> SAN JOAQUIN COUNTY <br /> 2` `z ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> a: a <br /> j 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> • UNIT IV <br /> rP Telephone: (209) 468-3454 Fax:(209)468-3433 Web:www.siaov.oralehd <br /> �/FOR <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> ggiman Hydraulic Garage-"MW11" 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 99 Address City 9 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 /> 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 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(i.e.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: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLYI <br /> I #OF WELL(S)TR <br /> BE DESTROYED OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs:MW1 i PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE U ED:❑9g,UGERS }SOS Ips USH O��M P qT(>3 FT) FT BELOW SURFACE <br /> COMMENTS_ _ �� cCGOrGIG 4a ilk Etf 1� OrDIJ l00 ✓1�G 6(tP 1 <br /> 5 WORKING DAYS NOTICE QUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> hereby certify t I have prep re is application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,a d II applicable If <br /> ornia 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 �//obi - <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE I + EA <br /> GROUT INSPECTION BY FINAL INSPECTION BY <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 <br /> �/ PR# <br /> $125 x / y S�� /J'`��7 / 5R#t,�,caY <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />