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°h°P ' SAN JOAQUIN COUNTYCOPI <br /> M•.c�a <br /> ?' ? ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone:(209) 468-3147 Fax:(209) 468-3433 Web:www.siaov.org/ehd 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 Development Title.Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 3139 E.Main St -Cross Street S .Golden Gate AvotylstateStockt:C 95205 APN 157-082-27 <br /> Proper4V, EI`T� __ J5,+9M,.^ T #170-7-I'7 <br /> --^ p)d+TJf�'ss 2351 Sunset Blvd CowlgilylStale 98768 Phone9T6-402-1499 <br /> C-57 Cant actor, Address9245 Beatty Dr. C ISjaapl __, . jo848359Phone916-363-9355 <br /> RD IIV1 ronmentT�c K JCA pct 7124hone 916-415-1134 <br /> Mi Sob Gntr Address6280 Brookshire Drc' /°sea La <br /> �B�e�i�yironmenta3 2n'cAddress6280 Brookshire DrC;iiy/°Stale — Zip 95677 PITI16-415-1134 <br /> c��cMic�ae errington <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> 0 NEW WELUBORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDB <br /> ®WELL IDs b <br /> • ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 1 [�MONITORING Lf HOLLOW STEM DIA.OF BOREHOLE 8 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _I]EXTRACTION:Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS S ch 40 TYPE OF CASING: ❑STEEL OPVC ❑ OTHER? <br /> _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 4 5 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ff PIPE <br /> _[I SOIL BORING El PUSH POINT(GP/CPT) GROUT SEAL PUMPED.4Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) SJCEHD specs <br /> • _0 INJECTION(.e.AV5aarae.Omne)❑HAND AUGER GROUT SPECIFICATIONS Neat cement yymixed in accordance W/ <br /> _O OTHER: ❑OTHER: APPROX.BORING DEPTH 6 5 Cr BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING[X No Cl Yes:Casing Ole: 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:tCHECK ALL THAT APPLY) <br /> #OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF_INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONSElEXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:E]AUGERS [-]HOSE ❑PIPE ❑MUSHROOM CAP AT(13 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 p epare this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulation d allljppl I C rnla laws. <br /> Signed A7 Title/Company Principal Geologist/RDM Environmental <br /> Print Name c ael A.6,Serrington Date 9-16-13 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE <br /> ADDRESS C9 !f- e¢rA1 T NL4OCreY7) <br /> WORK PLAN DATED 1' V R4 if(z I( I ZO I, 3 c <br /> APPLICATION ACCEPTED BY � D ;6-K DATE ISSUED T-2?`7 AREA 14 Yq <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> C OM M E N TSIC O N D I TI O N S: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> . REQUEST I PR# <br /> r7 (e 0( $125X f dl708 ckx.L VrGP- 'Zy I '� SR# (V15P <br /> h-1�3 �7S (3 00) <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER c-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ENCROACHMENT DOC A14 <br /> C-5 29-01 5/09172 WELL PERMIT APP <br />