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cor <br /> ;a�ly SAN JOAQUIN COUNTY <br /> 1 �� 2 ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> \'•.,+� 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> ?^d ` UNIT IV <br /> dt atsaN� Telephone: (209)468-3147 Fax:(209) 468-3433 Web:www.siaov.oraleh <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. <br /> Site Location 374 Lincoln Center Cross Street West Benjamin Holt City/State Stockton,CA Zip 95207 Ap�741029 <br /> Property <br /> Owner a w^r m.• Address 374 Lincoln Center City/State Stockton,CA Zip 95207 Phone 209-478-9200 <br /> C-57Contractor National E.W.P Address 1961 Meeker Ave City/State Richm_ontl,CA Lic 953646 Phone 510-236-6282 <br /> ConsultanVSub Cntr Address City/State Lic „_Phone <br /> Billable Party Geosyntec Consultants Address 3042 Gold Canal Drive Suite 201 CltylState ""�'�i°°"''c" Zip 9567_Phone 916-637-8048 <br /> GIS Coordinates:X 121.321172"W y-38—.00-8900r5*NN <br /> dVA >ao S /fir 5.2/S <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> E3 NEW WELUBORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AVGER,OTHER) <br /> ❑SOIL BORING IDS <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE_ Q MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor)Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL ❑PVC 0 OTHER <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> ._O SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes Q No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION Os.A,soarae Oeonel❑HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: 0 OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING 0 No Q Yes:Casing Dia: Casing Depth:_T Boring Dia:_ <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALLTHAT APPLY) <br /> .H__#OF WELL(S)TO BE DESTROYED IN OVERBORE DIAMETER OF Bearable INCHES TO DEPTH OF See Table FT <br /> WELL IDS: See Tws, [IPHESSU RE GRO UT TO DEPTH OF FTSELOW SURFACE <br /> GROUT SPECIFICATIONS Naol Cemmn(94 ii <br /> bap/Sflganans mamr ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO REUSED:9AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3FT) FT BELOW SURFACE <br /> COMMENTS Tables,figures,access agreement attached <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 /> Regulationlifornia laws. <br /> Signed �lL�' / <br /> Title/Company froject Geologist /vrtoJyn fct <br /> Print Name Timothy Davis Dale 8/22/2014 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS PPr 1Fle EIV d- 1 , 57*<*Tay <br /> WORK PLAN DATED '.1 4. l T-G0/ D <br /> APPLICATION ACCEPTED BY .I . OL9.CK DATE ISSUED S• 2r/� AREA G 17Q <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COM M E N TS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> �1 <br /> 70)_ <br /> REQUEST PR# <br /> of to $130z /LY04C) 22335 Z Rowv7L2 S-Z2.1q SR# - 383 <br /> 240 3 3 o 390 r (300 <br /> PR# <br /> 2900 <br /> C-57 V WC WAIVERAl_ C-57 LEITER OF AUTHORIZATION TO SIGN PERMIT V/ ENCROACHMENT DOC_6,A <br /> EHD 29-01 7/24114 WELL PERMIT APP <br />