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P°� oG SAN JOAQUIN COUNTY <br /> r' �+ ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> �� •. :P'` Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.sigov.orclleh UNIT IV <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> 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 Dev lopment Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> II .,trJ llowSF, it 'Z-oz- <br /> Site Location-V&4i44W444Q-" r \Cross Street N Center Street City/State Stockton Zip$5294 APN 139-020-03 <br /> Property Fk�fv NavwglJ'�n� %�\ 51 511`Vz cfrir — <br /> Owner ARS' Address P.O.Box W5T City/Slate "San-Remvn Zip -9468 Phone 925-275-3807 <br /> C-57 Contractor Cascade Drilling Address 3000 Duluth St. City/Slate West Saaamento Lie 938110 Phone 916-638-1169 <br /> Consultant/Sub Cntr 0RoAPBtpY•►MWAddress <br /> Vi Qo77)n�i,AN6 Ski City/State 0010ij Lie Phone 925•Z?% 3$07 <br /> Billable Party A'TRIOluTIC R<M'P&AcbAddress Po ani< IAS> City/State SAY Ra1�rQip 9ys83 Phone%Zs- A75• 380? <br /> GIS Coordinates:X '37.9467y Y -1AI.aZjgq <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:Vaporl 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 Cl HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION 0,e.Air Searae.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 APPLY) <br /> 1 #OF WELL(S)TO BE DESTROYED ElOVER-BOREDIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: MW-8 0 PRESSURE GROUT TO DEPTH OF 40.5 FT BELOW SURFACE <br /> GROUT SPECIFICATIONS 6 GAL OF WATER:ONE 94 LB SACK OF PORTLAND CEMENT ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE N PIPE MUSHROOM CAP AT(?3 FT) 3 FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I 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 /> Regulations,and all applicable California law/1s. <br /> Signed r� +�*^� `7o, W- Title/Company PROJECT MANAGER/BROADBENT&ASSOCIATES- <br /> 'j. <br /> Print Name JASON DUDA Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 16e• / '+eta fwe' LtJ 5 723LK7 <br /> WORK PLAN DATED Pj 09(ZtO / <br /> APPLICATION ACCEPTED BY J c910'<q!22 DATE ISSUED /2-Z-/4-k EA /619 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <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 /> c� REQUEST PR# <br /> 350 2 $ 130. p S q 228 Ocx ! SR# 7/083 <br /> RO# <br /> ac . <br /> )1� (3500) <br /> PR# <br /> C-57 WC WAIVER ^Jff C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT P' ENCROACHMENT DOC t0! <br /> EHD 2113-01 71201.1 WELL PERMIT APP <br />