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RECEIVED <br /> COPY <br /> u�`.co APR 01 20 SAN JOAQUIN COUNTY s <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> Q• <br /> rI{ ENVIRONMENTAL HEALTH <br /> PERMIT/SERVIC�O East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> �4•. �;;� elephone: (209) 468-3147 Fax: (209) 468-3433 Web. www.sigov.org/eh UNIT IV <br /> �/Foa <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. /7f-30Y- j <br /> Site Location 2431 E Mariposa Rd Cross Street Hwy 99 City Stockton Zip 95205 APN-9 1_939 03— <br /> Property <br /> Owner BJJ Trucking Address 2431 E Mariposa Rd City Stockton Zip 85205 Phone 209 466 9001 <br /> C-57 Contractor Advanced Geo EnviroAddress 837 Shaw Road Stockton 680227 209 467 1006 <br /> City Lic Phone <br /> Consultant/Sub Cntr Address City Lic Phone <br /> Billable Party Address City Zip Phone <br /> GIS Coordinates:X Y -r'2 /.2 3 8 3 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) 131-1310 <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 Cl MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> S❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 20 feet TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ❑PIPE <br /> o SOIL BORING ®PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION 0 a Air Soarne Ozones❑HAND AUGER GROUT SPECIFICATIONS Portland <br /> _❑OTHER: ❑OTHER: APPROX BORING DEPTH Meet ❑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 -Q OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ] PRESSURE GROUT To DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS O EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑ PIPE ❑MUSHROOM CAP AT(?3 FT) <br /> COMMENTS FT BELOW SURFACE <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 al_l a plicable Calif ryni�Signed ( F <br /> 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_ ,1 - f t'1 v4 s2 t�o f} I S TC1'<Toe-) <br /> WORK PLAN DATED M f}iZ r' /f j —) (q <br /> APPLICATION ACCEPTED BY DATE ISSUED 5-7-/y AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> tO3 <br /> NLY: AID# FAC# <br /> FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RID# INVOICE <br /> REQUEST PR# <br /> $125 x r `t G l � ` `/-, SR# g G37 S RO# <br /> (3500) <br /> PR# <br /> (2900) <br /> C v WAIVER h� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _/E NCROACHMENT DOC 77 WELL PERMIT APP <br />