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A•'•.'1•L �,r/ SAN JOAQUIN COUNTY 4010 <br /> FILE COPY <br /> a'T-A <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> - 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> Telephone:(209) 468-3147 Fax:(209) 468-3433 Web:www.siaov.ora/eh 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. 171-3m-13 <br /> Site Location 2431 E Mariposa Rd Cross Street Hwy 99 City Stockton Zip 95205 APN 174-930--f3- <br /> Property BJJ Trucking 2431 E Mariposa Rd Stockton 95205 209 466 9001 <br /> Owner 9 Address City Zip Phone <br /> C-57 contractor Advanced Geo EnviroAddress 837 Shaw Road City Stockton Lic 680227 Phone 209 467 1006 <br /> Consultant/Sub Cntr Address City Lic Phone <br /> Billable Party Address City Zip Phone <br /> GIS Coordinates:X Y -12 I ?06 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) BI-Bio <br /> ®SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING O HOLLOW STEM DIA OF BOREHOLE 2 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 20 feet TREMIE TYPE TO BE USED: IN AUGERS ❑HOSE ❑PIPE <br /> 1015 SOIL BORING ®PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION tie Ar soarve.Ozones❑RAND AUGER GROUT SPECIFICATIONS Portland <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 9n feet ❑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 Vl�icable_Califc la laws. <br /> Signed ��- �w �i L Title/Company Geologist/Advanced Geo Environmental <br /> Print Name William Little Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS ALM�I 57tU nW <br /> WORK PLAN DATED M 4=o t,I•I 3 I) Zv/�I _ <br /> APPLICATION ACCEPTED BY J- 0 alcu W\, DATE.M.ShM4f? IG <br /> GROUT INSPECTION BY FINAL INSPECTION BY �rr�� 7�•/y <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERERVICE UERO# INVOICE <br /> QST IR <br /> Z <br /> o(07_ $125, 2- o N -1 / SR# &Y 01, <br /> 1x10 yJ _ RO# <br /> 7 3500 <br /> PR# <br /> (2900) <br /> 457 // WC WAVER P6- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ik(/It ENCROACHMENT DOC <br /> EHD29-07 01/13112 WELLPERMRAPP <br />