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r • <br /> aQ`•'•ly. SAN .IOAQUIN COUNTY ORIGINAL <br /> 'z ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> " <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> UNIT IV <br /> .;p Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.siclov.org/ehd <br /> ./FO <br /> // WELL & BORING PERMIT APPLICATION V FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION O /\j <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 /> 3931 Newton Rd. Newton Rd&Cherokee Rd. Stockton,CA 95205 132-070-17 <br /> Site Location Cross Street City Zip APN <br /> Property Ken Gillies P.O.Hoz 8303 Stockton,CA 95205 (209)948-6268 <br /> Owner Address City Zip Phone <br /> chnicon Engineering 4539 N.Bmwley Ave.,Suite 108 Ci Fresno Lic 767888 Phone(559)276-9311 <br /> C-57 Contractor .TeServices,Inc. Address ty <br /> Consultant/Sub Cntr Address City Lic Phone <br /> Billable Party Technicon Engineering _ Address 4539 N.Hrawley Ave.,Suite 108 City Fresno Zip 93722 Phone (559)276-9311 <br /> -Services,Inc <br /> GIS Coordinates:X 0202 92CILLY--m <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW W OIL BORING <br /> (CPT,GEOPROBE,HVOROPUNCH,HAND-AUGER,OTHER) ^1 �.b , _ , A <br /> El SOIL BORING IDs [ ( �i�CCCJJJ���'''���•��- <br /> X WELL IDs GT-SVE"IA,IB 2A,1H 3A,&3B <br /> ❑OTHERIDs <br /> TYPE&#OF WELLIBORINGBi+hE PE CONSTRUCTION SPECIFICATIONS <br /> _❑MOX HOLLOW STEM DIA.OF BOREH10"/12"OLE [1 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> 40 <br /> _X <br /> EXTRACTION:Vapor/Water N CASING THICKNESS 025/Sch. TYPE OF CASING: ❑STEEL X PVC 13 OTHER <br /> U SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 15'/35 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> LA <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:X Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT). <br /> _❑INJECTION a e Alt Boame.Ozonel[I HAND AUGER GROUT SPECIFICATIONS <br /> One 94 lb.bag of Portland Cement for Every 6 gallons of water. <br /> _I]OTHER: ❑OTHER: APPROX.BORING DEPTH 40'/60' X BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASINGX No❑Yes:Casing Dia: Casing Depth:_ Boring Dia:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD,(CHECK ALL THAT APPLY) C—j( <br /> _#OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT y <br /> WELL IDs: <br /> FIRES GROUT TO DEPTH OF FT BELOW SURFACE L <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 Ff) 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 /> Re ul Ions,and Ila lieeble California laws. <br /> Signed / p Title/Company President&CEO/Technicon Engineering Services,Inc. <br /> PrinlN; Darren G.Williams <br /> Data Mey 4,2011 <br /> 3 DEPARTMENT USE 9YLYu 35.26 <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS N <br /> WORK PLAN DATED t Z <br /> APPLICATION ACCEPTED BY DATE ISSUED S• S• I AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICON DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE I RO# <br /> KWC <br /> AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# INVOICE <br /> $ �3Z a.� S•4• ( SR#0 <br /> At <br /> 3fdo. 7510 l ;°o Z6 <br /> IoaB # <br /> 29 <br /> WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT O PER ITAPP <br /> EHD 28-01 07/28/10 <br />