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' .o�qul" • SAN JOAQUIN COUNTY • FILE COPY <br /> —err t ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> v 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> P Telephone:(209) 468-3147 Fax: (209) 468-3433 Web:www.siaov.oro/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 compliancewith San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 1137 S. Stockton St Cross Street Navy Drive qty Stockton Zip 95206 APN 163-260-22 <br /> Property <br /> Owner Phillips, John B&Bonnie Address 1133 Bristol Ave City Stockton Zip 95204 Phone (209)944-0909 <br /> C-57 Contractor Advanced GeoEnviron.Address 837 Shaw Road City Stockton Lic 680227 Phone (209)467-1006 <br /> Consultant/Sub Cntr Advanced GeoEnvirAgdress 837 Shaw Road City Stockton Lic 680227 Phone (209)467-1006 <br /> Billable Party. Advanced GeoEnviron. Address 837 Shaw Road City Stockton Zip 95215 Phone (209)467-1006 <br /> GIS Coordinates:X 37.938270 Y -121.301328 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ®NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ®WELL IDs Six Sod Borings B16-B21 <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> — 2"MONITORING ❑HOLLOW STEM DIA OF BOREHOLE 2— ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _O EXTRACTION:Vapor/Water ❑HAMMERrDR VEN CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 10-15 FeetrREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE M]PIPE <br /> -9-K SOIL BORING IN PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes IN No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION fl..Ar Soame.ozones❑HAND AUGER GROUT SPECIFICATIONS 94 Ito baa Dorland cement mixed with 6 gallons of water <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 10 to 15 feet ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING CK No CIYes:Casing Dia: Casing Depth: Boring Dia: <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 Fr BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑ PIPE ❑MUSHROOM CAP AT L3 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,,,aaa—plicable Califoraia laws. <br /> Signed Title/Company Professional Geologist <br /> Print Name Brian Millman - Date 08 December 2014 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 1 lzlC r) <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY -/10 KLKu.P'X DATE „•" EA' <br /> GROUT INSPECTION BY FINAL INSPECTION BY J`( (t) DATE <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 /> REQUEST PR# <br /> & "MIZ /2401X/ SR# <br /> .�tv? 39U RO# <br /> (3500 <br /> PR# <br /> r� (2900) <br /> C-57�_� WC��WAIVER ,'' r C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOC <br /> EHD 29-001/13/12 WELL PERMI APP <br />