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rICUMI <br /> rau' _p • SAN JOAQUIN COUNTY • MAY 16 o COPY <br /> lrf ENVIRONMENTAL HEALTH DEPARTMENT P <br /> NVIRONMENTA�IM I�GATION <br /> 600 East Main Street, Stockton, CA 95202-3029 PERMIT/SERVECNIT IV <br /> -�;Fsaa <br /> Telephone: (209) 468-3147 Fax: (209)468-3433 Web: www.sigov.org/eh <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 1350 E Scotts Ave Cross street Wilson Way city Stockton Zip 95205 APN 151-310-10 <br /> Property <br /> owner Carl Blain Address 1450 E Scotts Ave city Stockton Zip 95205 Phone <br /> C-57 ontVBcCe eo nvlro Address 837 Shaw Road City Stockton L;c 95215 Phone 467-1006 <br /> Consultant/Sub Cntr Address City Lic Phone <br /> Billable Party AGE Address 837 Shaw Road City Stockton Zip 95215 Phone 467-1006 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> []k NEW WELLIBORING(CPT,GEOPROBE HYDROPUNCH,HAND-AUGER,OTHER) <br /> [2SOIL BORING IDs B1 to B3 <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING0 HOLLOW STEM DIA.OF BOREHOLE 1_25 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: t�J <br /> —0 EXTRACTION:Vapor/Water ❑HAMMERfDRIVEN CASING THICKNESS TYPE OF CASING: [I STEEL 0 PVC D OTHER <br /> 0 <br /> _ZQ9 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL 40 feet TREMIE TYPE TO BE USED: IN AUGERS D HOSE 0 PIPE <br /> II M SOIL BORING ®PUSH POINT(GP/CPT) GROUT SEAL PUMPED:(--)Yes [ No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION f e A'rsoame Ozone)0 HAND AUGER GROUT SPECIFICATIONS Portland <br /> _O OTHER: 0 OTHER: APPROX.BORING DEPTH 40 feet 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE O. <br /> CONDUCTOR CASING 0 No 0 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 WELL(S)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 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 applicable Cafll�a�laws. <br /> Signed 119(1 "A .h�s- Tille/Company Geologist/AGE <br /> Print Name William Little Date 05-16-2012 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS SV E /qu< <br /> WORK PLAN DATED 1 Zy 12 <br /> APPLICATION ACCEPTED BY DATE IS A <br /> GROUT INSPECTION BY r FINAL INSPECTION BY DATE)Q <br /> -a`I^/L <br /> DESTRUCTION INSPECTION BY DATE <br /> COM M ENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SREREQUEST PR#VICE RO# INVOICE <br /> $125x ! 2� 3io9q CTUMvt� A161 8,la2 sR# (oy470 <br /> �q0 37� 2� ROO# <br /> PR# <br /> 2900 <br /> C-57 r/ WC r/ WAIVER IV f/ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT L/ ENCROACHMENT DOC. JA I - <br /> EHD 29-01 01/13/12 WELL PERMIT APP <br />