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5nvl SAN .IOAQUIN COUNTY �¢ \ <br /> i¢-...y: <br /> !„ :s ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> `�a•.` :•�:P <br /> Telephone:(209)468-3147 Fax:(209)466-3433 Web:www.sicaov.orcI/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. <br /> Site Location 374 Lincoln Center Cross Street West Benjamin Holt City/State Stockton,CA Zip 95207 ApN 9741029 <br /> Property <br /> Owner u„m*r,ep.a:.vowax„w„no,ym,coq Address 374 Lincoln Center City/State Stockton,CA Zip 95207 Phone 209-478-92DO <br /> C-57 Contractor National E,W,P Address 1961 Meeker Ave CltylState Richmond,M Uc 953646 Phone 510-236-6282 <br /> Consultant/Sub Cntr Address City/State Uc Phone <br /> Billable Party Geosyntec Consultants Address 3042 Gold Canal Drive Suite 201 City/Stale "'ntliev'"°"^c" zip 95670 Phone 916-637-8048 <br /> GIS Coordinates:X 121.321172'W Y 38.008905*N <br /> CJS/O —12/ 22C. <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> D NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING [J HOLLOW STEM DIA.OF BOREHOLE_ ❑MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> _D EXTRACTION:Vapor/Water Q HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL ❑PVC D OTHER <br /> _D SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS D HOSE D PIPE <br /> _O SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes D No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _D INJECTION 0.Nr Scam-.Ozone)D HAND AUGER GROUT SPECIFICATIONS <br /> _O OTHER: ❑OTHER: APPROX,BORING DEPTH D BOLTED TRAFFIC BOX OR D STOVE PIPE <br /> COMMENTS; CONDUCTOR CASING D No D Yes:Casing DIa; Casing Depth:_ Boring Die:_ <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 0 OVER-BORE DIAMETER OF see Tame INCHES TO DEPTH OF See Tabla FT <br /> WELL IDs: see Table ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Neal Cemenl(94 to bag 1&6 gallons water ❑EXPLOSIVES FROM TD FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:M AUGERS LJHOSE EJPIPE -❑MUSHROOM CAP AT(>3 FT). 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 /> Regulations,ary(1 aU applicabl California laws. / <br /> Signed �i�-,_ G Title/Company Project Geologist / (yl foSy^f[c <br /> Print Name Timothy Davis Date 8/22/2014 <br /> Qn� <br /> DEPARTMENT USE ONLY ,�wr1 <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS I AA <br /> �� f{.gF('V yy(�.� S jY.�t J <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY ,J DATEISSUED 'ZS`/� AREA_LG27 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> qQ0 $130x3 U o 223352. mnu 2 C--2zay sR# 70-3 <br /> 2�7 QO RO# <br /> 3 3500 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER 06- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC <br /> EH029-01 7/24/14 WELLPERM11' PP <br />