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`- FILE COPY <br /> a,P4 •.,A SAN .JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> 1_ p Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.sigov.org/eh UNIT IV <br /> IFO � <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. �7/—Joo-/8 <br /> Site Location 2431 E Mariposa Rd Cross Street Hwy 99 City Stockton Zip 95205 APN 1g�yg� <br /> Property BJJ Trucking 2431 E Mariposa Rd Stockton 95205 209 466 9001 <br /> Owner 9 Address City Zip Phone <br /> G-57 Contractor Advanced Geo EnviroAddress 837 Shaw Road City Stockton Lic 680227 Phone 209 467 1006 <br /> ConsultanUSub Cntr Address City Lic Phone <br /> Billable Party Address City Zip Phone <br /> GIS Coordinates:XY ' /�-(•237cS <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) B1-B10 <br /> ®SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water ❑HAMMER/DRNEN CASING THICKNESS TYPE OF CASING: O STEEL ❑PVC ❑ OTHER <br /> _r1O�SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 20 feet TREMIE TYPE TO BE USED: EN AUGERS ❑HOSE ❑PIPE <br /> OL?SOIL BORING ®PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION(i a Ar Soerae.ozone)O HAND AUGER GROUT SPECIFICATIONS Portland <br /> _p OTHER: ❑OTHER: APPROX.BORING DEPTH 7n fPPt ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: <br /> Phase 11 workplan CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia:_ <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)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 SPECIFICATIONS ❑EXPLOSIVES FROM TO FT 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 application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all aprnl/p I <br /> Signed `��-`^ E) Title/Company Geologist/Advanced Geo EnvironmEntal <br /> Print Name William Little Date U5i l O/ 2-0/ <br /> �1 ? DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IVFILE-SITE ADDRESS /� -� 1 C. MAR/P6SR QM( S7Z�A'7D.t/ <br /> WORT(PLAN DATED RCzzwl <br /> APPLICATION ACCEPTED BY --I•`.�V f}KN.rvI DATE REF(0 <br /> GROUT INSPECTION BY FINAL INSPECTION BY T <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 SEREQURVICE RO# INVOICE <br /> �pC ESTp PR# <br /> 2• $125X / SR# <br /> 3 7 (3o0 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER 0} C-57 LITTER OF AUTHORIZATION TO SIGN PERMIT /L ENCROACHMENT DOC <br /> EHD 29-01 01/13/12 WELL PERMI APP <br />