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' ; <br /> •.a SAN JOAQUIN COUNTY COO I <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> oR� Telephone:(209) 468-3147 Fax:(209)468-3433 Web:www-sigov.oraleh 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. <br /> Site Location 6455 Pacific Ave Cross Street West Benjamin HoltCity/Stale Stockton,CA Zip 95207 Ap(,�9741029 <br /> Property <br /> Owner Address 2500 Ventura Oaks Way City/State S.mmT' nw,cA Zp 95333 Phone 916-646-8211 <br /> C-57 Contractor National E,W.P Address 1961 Meeker Ave City/State Richmond,CA Uc 953646 Phone 510-236-6282 <br /> Consultant/Sub Cntr Address City/Slate LIc�T Phone <br /> Billable Party Geosyntec Consultants Address 3042 Gold Canal Drive Suite 201 City/Stale "'""'°`°"°^`" Zip 95670 Phone 916-637-8048 <br /> GIS Coordinates;X 121.321172'W y 38.008905'N <br /> —/z, Zz y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> Q SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs - <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> —0 MONITORING EI HOLLOW STEM DIA OF BOREHOLE_ 0 MULTIPLE CASINGS E7 MULTI-LEVEL WELL CASING DIA: <br /> _O EXTRACTION:Vaporl Water 0 HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 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 /> _0 SOIL BORING 0 PUSH POINT(GP1 CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _D INJECTION(1.-.9,spam.Ozonet O HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: 0 OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> COMMENTS; CONDUCTOR CASING O No 0 Yes:Casing Dia:_Casing Depth:_ Boring Did:__ <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> -L-_*OF WELL(S)TO Be DESTROYED ©OVER-BORE DIAMETER OF S--7 a INCHES TO DEPTH OF Sea Tablo FT <br /> WELL IDs: SVE-osaand SVE.e32 O PRESSURE GROUT TO DEPTH OF Se.Tobe FT BELOW SURFACE <br /> GROUT SPECIFICATIONS N..t Cement(g4robeelse gallon.water O EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:®AUGERS ❑HOSE ❑PIPE Q MUSHROOM CAP AT(>3 FT) 3 FT BELOW SURFACE <br /> COMMENTS Tables.figures access agreement and data For pressure grouting attached <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 1 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 /> Regulatlons(t al`appll /bI),C,alifornia laws. / <br /> Signed J� v ` - Title/Company Prot Geologist 167COSyllCr <br /> Print Name Timothy Davis Dale 8/22/2014 <br /> t�� EPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS r ±d 1 LN /7/-1 „4r <br /> WORK PLAN DATED La. Li /a. <br /> APPLICATION ACCEPTED BY DATEISSUED fg-ZS'/fir AREA 16 49 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAG# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> [�.� �I REQUEST PR# <br /> q oZ 8130% fe 22,:t352 `awrNTEe C Z2-1q SR#0070TC <br /> `v� a 3 Io RO# <br /> 3600 <br /> PR# <br /> (290 0) <br /> C-57= WC V WAIVER,�jf C-57 LETTER OF AUTHORIZATION TO$IGN PERMIT L-' ENCROACHDOC LI 1!9 _ <br /> EHD 29-01 7/24/14 WELL PERMIT APP <br />