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c <br /> F11 <br /> o�a`''� c SAN .10AQUIN COUNTY .• r ppy <br /> ENVIRONMENTAL HEALTH DEPARTMENT y_ . ..:. . •'KLOP <br /> "':`• -6232 SITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton, CA 95205 <br /> • �` •- P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehd 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 6833 East Main Street Cross Street Alpine Road City/State Stockton Zip 95215 APN 10105002 <br /> Property <br /> Owner Richard Bozzano&FE Address 3000 N Arata City/State Stockton Zip 95205 Phone 209-986-9091 <br /> C-57 Contractor Cascade Drilling,L.P. Address 3632 Omec Circle Rancho <br /> Cily/State Cordova Lic 938110 Phone 916-638-1169 <br /> Consultant/Sub Cntr Address City/State Lic Phone <br /> Billable Party Address City/State Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL./BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _225aMONITORING VHOLLOW STEM DIA.OF BOREHOLE 8.2511 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 2" <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS SCh 40 TYPE OF CASING: ❑STEEL ❑PVC V OTHER Plastic <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 39' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(I.e A r Soarae.Ozonel❑HAND AUGER GROUT SPECIFICATIONS Neat Cement <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 61' W BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING16 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) <br /> #OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑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 hav pmpared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulation,ad alapple able California laws. <br /> Signed Title/Company General Manager/Cascade Drilling, L.P. <br /> Print Name Paul Snelgrove Date 2/27/2013 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY j•O/og<lf n I, DATE IS iG 72 <br /> GROUT INSPECTION BY FINAL INSPECTION BY „_QATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> �q q REQUEST PPRZ# <br /> �2�0 <br /> $125, 2 y��J l �OLtnir 3 SR# G J <br /> 290 75 R3 00) <br /> PR# <br /> (2900) <br /> C-57_f-_ WC WAIVER_ 2 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT 2/ ENCROACHMENT DOCS <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />