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9ECEIVE® <br /> �rFo, i SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SSP B 6 2Qi2 <br /> {" LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-62ENVIRONMENTALTIGATION <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sm @ N1kT/b1EEV1�6S IT IV <br /> WELL & BORING PERMIT APPLICATION ••f• ��_� <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND R!on <br /> EMnincomplauaan NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct antl/or install the work described. This applicatis m <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 6100 N.HWY 99 Cross Street Hammer LaneStockton <br /> Ciry/State Zip APN 06704034 <br /> Property <br /> owner Scannavino Properties Address 5463 Cherokee Road Stockton <br /> City/State Zip Phone 209.931.3570 <br /> C-57 Contractor Cascade Address 3632 Omec Circle City/State Ranc comwa LiC 957422Phone 916.638.1169 <br /> ConsultanVSub Cntr Arcadis Address 950 Glen Drive Suite 125 Ciry/State Folsom Lic Phone 916.965.2079 <br /> Billable Party Arcadia <br /> GIS Coordinates:XAddress City/State Zip Phone <br /> -j- '7�9v7.���dy Ad rens,�SGi6yj�jgpd <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ®WELL IDsSVE-1.SVE-2 <br /> ❑OTHER IDs <br /> TYPE&#OF WELLBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ®HOLLOW STEM DIA.OF BOREHOLE 110" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 4„ <br /> EXTRACTION: apo Water ❑HAMMER/DRIVEN CASING THICKNESS SCH 40 TYPE OF CASING: ❑STEEL t<]PVC OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 51' TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ❑PIPE <br /> _O SOIL BORING &m ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:[3 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> a e [I HAND AUGER GROUT SPECIFICATIONS <br /> —❑OTHER: ❑OTHER: APPROX.BORING DEPTH 70' ®BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING El No❑Yes:Casing Dia: Casing Depth: Boring Die: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORT(TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: E]PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <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,and all applicable California laws. <br /> Signed �� U . 1,—� Title/Company Staff Scientist <br /> Print Name Amber V.Nickens Date .S"T- S. ?-o 1-2— <br /> DEPARTMENT <br /> DEPARTMENT USE ONLY A <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED B DATE 19 EA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE I .2042 <br /> DESTRUCTION INSPECTIOqBYU DATE <br /> COMMENT&CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> REQUEST PR'0 <br /> ,JJ-O/ $125, a o7.S0- 00 SR# Q <br /> 0,3 37,j00 %✓`LOfi (3500)COC-0 <br /> 70 <br /> PR# <br /> 2900 <br /> WC WAIVER <br /> EHD C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 5/08/12 WELL PERMIT APP <br />