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FILE COPY <br /> P4 1" SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> UNIT IV <br /> Telephone:(209)468-3454 Fax:(209) 468-3433 Web:www.sigov.orG/ehd <br /> �/FOR <br /> ` I WELL & BORING PERMIT APPLICATION <br /> V a FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION O <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 Address P.O.Box 8303 City Stockton,CA Zip 95205 phone (209)948-6268 <br /> Owner <br /> Technimn Engineering 4539 N.Brawley Ave.,Suite 108 Fresno 767888 {559)276-9311 <br /> C-57 Contractor Sech"'co E Address City Uc Phone <br /> Consultant/Sub Cntr Address City Lic - Phone <br /> Billable Party <br /> Technicon Engineering Address city P on <br /> 4539 N.Brawley Ave.,Suite 108 Ci Fresno Zip 93722 phone (559)276-9311 <br /> - _ <br /> Services,Inc. <br /> GIS Coordinates:X Y —12.1 21, <br /> CONSTRUCTION ING(CP TO BE PERFORMED: "— <br /> _❑NEW I SOILBOR IN (CPT,GEOPROBE,HVDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs SVE#1A,1B 2A,oB 3A,&3B <br /> X WELL IDs iT <br /> [:1 OTHER IDs <br /> TYPE&#OF WELL/BORING PE CONSTRUCTION SPECIFICATIONS <br /> 10"/12" <br /> 11 MO�OR4 1,8_— - 1 X HOLLOW STEM DIA.OF BOREHOLE _❑MULTIPLE CASINGS LI MULTI <br /> WELL CASING DIA <br /> =X EXTRACTION:Vapor/Water N CASING THICKNESS 025/Sch 40 TYPE OF CASING: 1]STEEL X PVC ❑ OTHER uj <br /> ❑MUD ROTARY DEPTH OF GROUT SEAL 1>/35 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _[I SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:X Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 Fri <br /> _❑INJECTION C AI s ozor,er[I HAND AUGER GROUT SPECIFICATIONS <br /> One 9$lb.bag of Portland Cement for Every 6 gallons of water. <br /> _I]OTHER: ❑OTHER: APPROX.BORING DEPTH 40'160' X BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING X No❑Yes:Casing Dla: Casing Depth:_ Baring Dia:_ <br /> COMMENTS: (I <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUcnoNMETHOD,(CHECK ALL THAT APPLY) C—tI <br /> _#OF WELL(S)TO BE DESTROYED I-]OVER-BOREDIAMETER 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 /> Regul ions,and all a Iteehie California laws. V 1 <br /> Signed <br /> Title/Company President&CEO/Technicon Engineering Services,Inc. <br /> Print N; Darten G.Williams Date May 4,201] <br /> 3 DEPARTMENT USE L 35•�� Lo P <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS �•'t <br /> WORK PLAN DATED tl 2 <br /> APPLICATION ACCEPTED BY DATE ISSUED S' S• I AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: ° <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RD# INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# <br /> 35(7 <br /> $122 x (0 a40mr. 5.4- ( SR#0 <br /> 3 (4•v, 3G� 25to I R 00 <br /> 503 Z(o <br /> loo$ 29 <br /> EH0729-01 o7/2Bno C WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC N <br /> L E COP ER IT APP <br />