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RECEIVED - t " <br /> UI / 00 e <br /> A4 " <br /> cAPR O 1 ZOM SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> rV ` ENVIRONMENTAL HEALTH SITE MITIGATION <br /> PERMIT/SERVICjN0 East Main Street, Stockton, CA 95202-3029 <br /> • �q.. j :�;;P. telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/eh UNIT IV <br /> {fFOR <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/-3c)c -o3 <br /> Site Location 2431 E Mariposa Rd Cross Street Hwy 99 City Stockton Zip 95205 APN - <br /> Property <br /> Owner 9 BJJ Trucking Address City Zip Phone <br /> 2431 E Mariposa Rd Stockton 95205 209 466 9001 <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 2"7.9',S I Y - ( "z /•Z g a 3 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) g1-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 /> _❑EXTRACTION Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 20 feet TREMIE TYPE TO BE USED: IN AUGERS ❑HOSE ❑PIPE <br /> SOIL BORING (9 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 Fr) <br /> _❑INJECTION(i e Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS Portland <br /> _❑OTHER: El OTHERAPPROX BORING DEPTH 4a fARt �S(Y L ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: <br /> Phase II 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 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all+a plicable Calif rn�1i <br /> Ii,-1( �1 !✓L y � Geologist/Advanced Geo Environmental <br /> Signed Title/Company <br /> Print Name William Little Date 2-// e 7/.2aw<-Z <br /> DEPARTMENT USE ONLY t� <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS W / C `"? vie(/16 5f} R I s' <Tc�, <br /> WORK PLAN DATED 114/}IZ E f f <br /> APPLICATION ACCEPTED BY _`�O f3-K DATE I �WIWEA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITI ONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE S <br /> rrte'' R <br /> vS $125x �`(Gl �ctitVr y-/-1� S <br /> �z AG 37 S RO# <br /> (3500) <br /> PR# <br /> (2900) <br /> C-57� WC ci WAIVER i✓ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT �/ ,✓ENCROACHMENT DOC Ny' <br /> EHD 29-01 1/13/12 WELL PERMIT APP <br />