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Copy , <br /> on4 tti�.. <br /> p�57E �.,.. t..,e` SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Lop <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATIONUNIT IV <br /> Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.sigov.org/eh <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 Developme4qt T�it�le Chapter 9- 115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Szz N.V4 .%eA.,S <br /> Site Location 437 East Miner Ave Cross Street Calif-MI.street Ci1ylState sk,okton,CA Zip 95202 APN 139-24-009 <br /> Property <br /> Owner Chavmn Environmental Management Address 6111 Bollinger Canyon Rd,Room 3652 City/State sen Ramon.CA Zip 94583 Phone 925.543-2349 <br /> C-57COntractor Cascade Drilling LLC Address 3000Dululh8uset City/State Wesi Sao,CA LIC 938110 Phone 9164638.1168 <br /> Consultant/Sub Cntr ARCADISU.S.,Inc. Address 101 Creeksido Ridge Court,Suite 200 City/State Roseville,CA LIC Phone g1678"32o <br /> Billable Party 1A00AD14 0). AJC,_ Address 41 AhrM City/State Zip Phone <br /> GIS Coordinates:X 37,4572. Y —)Z/�ZP.H83 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&If OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS 13 MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL O PVC O OTHER <br /> _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> —0 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION n.e A,Soame.Czm¢t❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> 3 #OFWELL(S)TOBE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: u-1+.0-12 LL13 ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS e•x•.m.m ❑/ EXPLOSIVES FROM sN am.n.,, TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:Lj AUGERS LJHOSE PIPE ❑ MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS SeeblastDi.nf.,Individu.i..Ilexpl.sivesi.leals. <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,an��Innnd .all/applicable California laws. <br /> W <br /> Signed /I 1. r.-)2 !r (( --' Title/Company Project Scientist/ARCADIS U.S.,Inc. <br /> Print Name Aw D.Munn Date September 5,2014 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS y3 ((191V E'e <br /> WORK PLAN DATED .SC PTE//7 it 20/ V _ <br /> APPLICATION ACCEPTED BY 3 . t[a ig-ki4w) DATE ISSUED AREA_/d99 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> C O M M E N TSI CO N D ITI O N S: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> REQUEST PR# <br /> 35 vZ $13OX 3 � ZvG� e UVVrk -/()_/ SR# ?O}5 <br /> 3S_03 3170 3 00 <br /> PR# <br /> (2900 <br /> C-57 / WC WAIVER tt/J�­ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC A ✓A7 <br /> EHD 29-01 7T4114 WELL PERMIT APP <br />