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00 <br /> SAN .JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> •..'.: jp� Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.si4ov.orGleh 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 Developmey Title Chapter 9-11115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> 322 N.CAc r <br /> Site Location 437 East Miner Ave $mss Street caltromla street City/State sloelnm,,cA Zp s52oz ApN 139-24-009 <br /> Property <br /> Owner Chavmn i5mimnmantal Management Address 6111 Bollinger Canyon Rd,Room 3652 City/Sial¢ San Rem.,CA Zip 94583 phone 92S54b2349 <br /> C-57 Contractor Cascade Drilling LLC Address 3000 Duluth Street City/State West Sac,CA LIC 938110 phone 918b384169 <br /> CODSUIIant/BDb Cntr ARCADIS U.S.,Inc. Address l01Creeka1de Ridge Coun,Su)ts200 City/Slate Roseville,CA LlcPhone 916-786-0320 <br /> Billable Party 1}P,l1A IIs IAS Address &APSE City/State Zip Phone <br /> GIS Coordinates:X37'4;72o y —M/,28yg3 <br /> CONSTRUCTION WORK TO BE PERFORMED• <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHERIDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Cl STEEL 0 PVC 0 OTHER <br /> _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS ❑HOSE 0 PIPE <br /> _O SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION Ga Ar Soame.Ozone)O HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: ❑OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING 0 No❑Yes:Casing Dia: Casing Depth: Boring Ola:_ <br /> NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD rCHECK ALL THAT APPLY) <br /> 3 #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs:SPECIFICATIONS <br /> ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS tr••� n� [7]EXPLOSIVES FROM am Bm-1 TO •a•U•a FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:LI AUGERS UHOSE PIPE ❑ MUSHROOM CAP AT L3 FT) Fr BELOW SURFACE <br /> COMMENTS gee blest plan for Individual yell I 1 I <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 1 hereby certify that.)have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all <br /> applicable California laws. <br /> Signed LLQ (/ l(,t*J 4-. Title/Company Project Scientist/ARCADIS U.S..Inc. <br /> Print Name AW o.Munn <br /> Date September 5,2014 <br /> u DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS y� F. 014/4'EE '46t, 5raeKl-40 <br /> WORK PLAN DATED 24)0-1 <br /> APPLICATION ACCEPTED BY _ J `t(a 6-/l DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> C O M M E NTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> �q REQUEST PR# <br /> '350 Z $130X 3 l 'YAG &UIVPElz -lp_/ SR# <br /> Xo3 390 RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 _ r/ WC WAIVER�i� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT /� ENCROACHMENT DOC /L PQ <br /> EHD 29-01 714/14 - WELL PERMIT APP <br />