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SAN JOAQUIN COUNTY <br /> LOP <br /> ENVIRONMENTAL HEALTH DEPARTMENT� SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 _ UNIT IV <br /> Telephone:(209) 468-3454 Fax:(209)468-3433 Web:www.siaov.oralehd <br /> �LF OYri� <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 145 South Sutter St cross street Washington cityStockton Zip95202 APIA 149-15-024 <br /> Property San Joaqvin County <br /> Owner Facilities Management Address44 N. San Toacfuin St cityStockton ZP95202 Phone(209)468-5564 <br /> C-57 Contractor Test America Address3195 Luyung Drive City Ranch Cordoval-05742 Phone(916) 638-5564 <br /> ConsuRanUSub CnOeston Solutionsgddress428 13th St, 6th Fl CityOakland Lj0522739 Phone(510) 788-3801 <br /> San Joaquin�o—=—Ty 44 N. San Soa in St Stockton 95202 (209)468-5564 <br /> Billable Party Address City Zip Phone <br /> GIS Coordinates:X4201B23 Y650633 NAD 83 UTM10N <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ®NEW WELUBORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> M WELL IDS MW-1 <br /> [:]OTHER IDs <br /> TYPE 811 OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> M MONITORING 99 HOLLOW STEM DIA.OF BOREHOLE 8" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DV+: 2 n <br /> _0 EXTRACTION:Vapod Water 0 HAMMER/DRIVEN CASING THICKNESS SCh. 4 0 TYPE OF CASING: 0 STEEL 91 PVC ❑ OTHER <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TBD TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> _O SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION 6,ar Soame Ozone)0 HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: 0 OTHER: APPROX.BORING DEPTH 12 0 ®BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING EI 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 /> #OFWELL(S)TOBE DESTROYED El OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WE_LL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:ElAUGERS ❑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 IP ared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,,7�'F1 11 applies le Calrtomfa laws- <br /> Signed J 1 - TmercompanyProject Manager, Weston Solutions <br /> Print NameThO CrtT1e. ris rDSIsSeptember 21 2010 <br /> DEPARTMENT USE O <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS I �� S fit S <br /> WORK PLAN DATED m 20 <br /> APPLICATION ACCEPTED BY � AA���"C� DATE ISSUED AREA <br /> GROUT INSPECTION BY _ftp Z FINAL INSPECTION BY DATE z ; <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> REQUEST I PRA <br /> 35-ol $122, l 12z.00 SR# (61l <br /> 35t)3, 366.00 = q?q <br /> PR# <br /> 4800 <br /> G-57 Wt; WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓' ENCROACHMENT DOC <br /> EHD 28-01 07/M10 WELL PERMIT APP <br />