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ea�fn. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> 600 East Main Street,Stockton,CA 95202-3029 UNIT IV <br /> �'•. >* Telephone:(209)4683454 Fax:(209)468.3433 Web:www.siaov.ora/ehd <br /> tiKd'd <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 Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> 3940 N Tracy Blvd Larch Road ` 3�1 0 <br /> Site Location Cross Street City Tracy Zip CA 95304 APN 2122000 <br /> Property Charanjit&Davinder Jutla <br /> Owner Address 3940 N Tracy Blvd City Tracy Zip CA 95304 Phone <br /> C-57 Contractor Clearwater Group Address 229 Tewksbury Avenue City Pt. Richmond Lic 799370 Phone 510-307-9943/590-1099 <br /> ConsuifanVSub Cntr'1rnl Adini&Associateslnc. Address 4609 Russell Avenue City Los Angeles Lic 567540 Phone 323-913-4073 <br /> Billable Party Ami Adinr&Assodates Inc. Address 4609 Russell Avenue City, Los Angeles Zip CA 90027 Phone 323-913-4073 <br /> GIS Coordinates:X 6291616.02' y 2102640.76' <br /> E <br /> CQNSTRUCTION WORK TO BE PERFORMED• <br /> +j NEW WELL/BORNG(CPT <br /> +1 SOIL BORING IDs ITuree(B5-07) <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WEWBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE _❑MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL + PVC ❑ OTHER_ <br /> _D SOIL VAPOR PROBE ❑MVD ROTARY DEPTH OF GROUT SEAL 2O TREMIE TYPE TO BE USED: ❑AUGERS + HOSE ❑PIPE --P <br /> + SOIL BORING + PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes + No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _D INJECTION rl.e.Av sparge,cone + HAND AUGER to 5'bgs GROUT SPECIFICATIONS Bentonite Cement Slurry <br /> D OTHER: D OTHER: APPROX.BORING DEPTH 20 feet + BOLTED TRAFFIC BOX OR D STOVE PIPE <br /> CONDUCTOR CASING❑No D Yes:Casing Dia: Casing Depth:_ Bodng DO <br /> COMMENTS: Fo..ddm1411e11 111,w,,...11111. n„n wa,knh,, <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THATAPPLYI <br /> _#OF WELL(S)TO BE DESTROYED C]OVER-BORE DIAMETER OF_INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE r� <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS `�(\1 <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby fy the I h repared this appliation and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulatbn da ble Callfor da laws. I p;) <br /> Signed Tide/Company Seay- I ISM 0 GI�r ul4 ter Group vim' <br /> Print Na J Date 8/.23110 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 42-5 La r .)'1 R n q <br /> WORK PLAN DATED Ma 0 I O <br /> APPLICATION ACCEPTED,/BY I DATEISSUED 9' 3—/0 AREA 14 S q <br /> GROUT INSPECTION BY Y.IdhirrA )41edzb”gpVtb FINAL INSPECTION BY VI GTtlY Ib )Xtdlirl-Aj _ DATE 917-VkU <br /> DESTRUCTION INSPECTION BY r-7— DATE '7""- <br /> COMMENTS/CONDITIONS: •I j <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES I FEE INFO All REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> REQUEST PR# <br /> 35'05- $122. / /.22. 0d q- -/d SR# 006 a 977 <br /> 3SQ 3 366. 00 "3 Lb. 00 Ro# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C.57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> END 29-01 07PM10 <br /> WELL PERMIT APP <br />