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• <br /> SAN JOAQUIN COUNTY <br /> • FILE UPY <br /> E -f ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> _ <br /> -;-. Telephone: (209) 468-3147 Fax:(209) 468-3433 Web: www.siaov.ora/eh UNIT IV <br /> /FORS <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 1400 E Scotts Ave cross Street Wilson Way city Stockton Zip 95205 APN 151-310-43 <br /> Property <br /> Owner Carl Blain Address 1450 E Scotts Ave city Stockton Zip 95205 Phone <br /> vaflce eo nvlro 837 Shaw Road Stockton <br /> C-57 ontracior Address City Lie�5'2'1CJ Phone 467-1006 <br /> Consultant/Sub Cntr Address City Lic Phone <br /> Billable Parry AGE Address 837 Shaw Road city Stockton zip 95215 Phone 467-1006 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> [3t NEW WELL/BORING(CPT,GEOPROBE HYDROPUNCH,HAND-AUGER,OTHER) <br /> I$SOIL BORING IDs B4 to R6 <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _ <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1.25 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC [IOTHER 8 <br /> _ZIN SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 40 feet TREMIE TYPE TO BE USED: IM AUGERS ❑HOSE 0 PIPE {� <br /> KI SOIL BORING ®PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION(I.Nr Soame.Ozone)O HAND AUGER GROUT SPECIFICATIONS portland <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 40 feet 0 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No 0 Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS C. <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ❑OVERBORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: [IPRESSURE 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 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 app�)�"cIifor <br /> able CalI aws. <br /> Signed _ Title/Company Geologist/AGE <br /> Print Name William Little Date 05-16-2012 <br /> 1 DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS iso F SC'oTPS /3U6 <br /> WORK PLAN DATED /Z dme� W2 <br /> APPLICATION ACCEPTED BY JHO�KuIa'I DATE I EA /(,99 <br /> GROUT INSPECTION BY FINAL INSPECTION BY TES-Z4d Z <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATESERVICE RO# INVOICE <br /> REQUEST PR# <br /> 2 clOj- $125, / 3 75— 6&r Tc,e Ytf6 SR# <br /> zqo 3 3 n _ R°o <br /> PR# <br /> 2900 <br /> C-57 v WC WAIVER Aj Y�-_ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT 'Ii ENCROACHMENT DOCS <br /> EHD 29-01 01/13/12 WELL PERMIT APP <br />