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FILE COPY <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> 1868 Hazefton Avenue, Stockton, CA 95205-6232 SITE MMGATION <br /> . Telephone:(209)466-3147 Fax:(209)468-3433 Web:www.slaov.ord/ehd UNIT IV <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATION$AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicatlon 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 Sen <br /> Joaquin County Development T"�le,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Departrnent. <br /> French Site Location 500 W. Hospital Rd_.CrossStnet S. Manthey Rd. CftylStatecamp, CA Zip 95231 APN 193-050-10 <br /> Property <br /> Owner San Joaquin County Address <br /> City/State L'p Phone <br /> C-57 Contraetor:.=azan & A, Inc. Address 215 W. Dakota Ave. City/State clo--is, c:-, Lie 499908 <br /> Krizen phone(559) 348-2200 <br /> CDrmultant/SubCntr......-.=.o. Address 215 W. Dakota Ave. CttylState Clovis, ca L1e 499908 Phone (559) 348-2200 <br /> Billable Party Address CltylState Zlp Phone <br /> GIS Coordinates:X 37 . 886439 Y-121.282719 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IQs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE 8 k OF WELLBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 4 .5" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DLA: <br /> ❑EXTRACTION:Vaporl Water ❑HAMMERIDRNEN CASING THICKNESS TYPE OF CASING; ❑STEEL ❑PVC ❑ OTHER <br /> _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 20 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> 3 M SOIL BORING ❑PUSH POINT(GPJ CPT) GROUT SEAL PUMPED:p Yea ❑No(MAXIMUM FREE FALL DEPTH IS 30 F7) <br /> _❑INJECTION 0 ALa=M&1I=a1❑HANDAUGER GROVrSPEC1FICATIONS 94 Type I-II Cement/ 6 Gallons Water <br /> _❑OTHER ❑OTHER: APPROX BORING DEPTH 2 0" E]BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING❑NO❑Yes:Casing Dia: Casing Depth: Boring Dla: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD'(CHECK ALL THAT APta n <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> H OF <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTFT BELOW SURFACE <br /> GROUT SPECIFICATIONS El EXPLOSIVES FROM To Fr BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) 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 applico4n and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,e a pl ti to Califor�yt laws. <br /> Signed 4 (dJ Title/Company <br /> -Senior Manager Krazan & Associates, Inc <br /> PdntName Michael i3owery Date 4/28/14 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS ��� IN. D/ �79 l R�//►4 t� ��� �`jf <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE I <br /> GROUT INSPECTION BY FINAL INSPECTION AREA <br /> BY kit DATE - -r <br /> DESTRUCTION INSPECTION BY DATE w <br /> COMM ENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> 0 REQUEST PR <br /> $125x l SIL/ SR# S <br /> 2 D� ���J FfDODII040 RO# <br /> 3500 <br /> PR# <br /> __ 2900 <br /> C-57 _ WC F WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 28-01 9112 <br /> Q S S 7 - WELL PERMIT APP <br />