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RECEiVFD <br /> �o�4t.co APR O 1 20 SAN JOAQUIN COUNTY OPIG <br /> ��I A <br /> F -rFr S <br /> t `X ENVIRONMENTAL HEALTH DEPARTMENT <br /> ENVIRONMENTAL HEALTH LOP <br /> NVI <br /> TERMfT(SERVIC00 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> elephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/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. /?t-j�i-o3 <br /> Site Location 2431 E Mariposa Rd Cross Street Hwy 99 City Stockton Zip 95205 APN-9 7-a-030 03 <br /> � <br /> Property BJJ Trucking 2431 E Mari osa Rd Stockton <br /> Owner 9 Address p City Zip 95205 phone 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 /-9 S I Y -/ 2 /•2 48 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 /> S <br /> y�❑,,,SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 20 feet TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE [I PIPE atL SOIL BORING ®PUSH POINT(GP/CPT) GROUT SEAL PUMPED ❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e Air Soame Ozones❑HAND AUGER GROUT SPECIFICATIONS Portland <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH--WrfeAt �JF-Y� ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS. <br /> Phase If 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 a plicable Calif rni �rvs <br /> Signed `l(� 1' 1 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 A W 3) C I M i}R(Ao <br /> WORK PLAN DATED IVI /4-2t1f �/a 2-0 (q <br /> APPLICATION ACCEPTED BY 1_`�O r+& DATE ISSUED 5-7-(gI AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <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 SERVICE RO# INVOICE <br /> �\ REQUEST PR# <br /> Ver' $125x XJ�G1 (�c�rVr y -1 SR# 4 g G <br /> RO# <br /> (3500) <br /> PR# <br /> (2900) <br /> C-57 WC v WAIVER N/ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC N <br /> EHD 29-01 1/13/12 WELL PERMIT APP <br />