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Pq"t`�' SAN JOAQUIN COUNTY , <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />• : — 600 East Main Street, Stockton, CA 95202-3029 <br />.. �;;P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.orq/eh <br />� hi o. <br />LOP <br />SITE MITIGATION <br />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 7373 West Lane Cross Street Hammertown Drive City Stockton <br />Property <br />Owner Kaiser Permanente Address 7373 West Lane City Stockton <br />Advanced Stockton <br />C-57 Contractor GeoEnvironmental Inc. Address 837 Shaw Road City <br />Zip 95210 APN <br />Zip 95210 Phone 209-476-5408 <br />Lic 95215 Phone 209-467-1006 <br />vance Stockton <br />Consultant/Sub Cntr GeoEnvironmentai ,Inc. Address 837 Shaw Road City Lic 95215 Phone 209-467-1006 <br />�7 <br />Advanced Stockton <br />Billable Party ceoEnvironmental, Inc. Address 837 Shaw Road City Zip9521 Phone 2&-V f, lJ;! 4o <br />GIS Coordinates: X Y <br />.��I►�3� i�Z�L�7►1'�rLOI:76L� <br />LTJ NEW WELUBORING (CPT OPROBE YDROPUNCH, HAND -AUGER, OTHER) <br />® SOIL BORING IDs U , 3, 4, 5, 6, 7 <br />❑ WELL IDs <br />AID # <br />❑ OTHER IDs <br />PE CODES <br />TYPE & # OF WELUBORING <br />INSTALLATION TYPE <br />_❑ MONITORING <br />❑ HOLLOW STEM <br />_❑ EXTRACTION: Vapor/ Water <br />❑ HAMMER/DRIVEN <br />_❑ SOIL VAPOR PROBE <br />❑ MUD ROTARY <br />7_❑ SOIL BORING <br />I@ PUSH POINT (GP/ CPT) <br />_❑ INJECTION (i.e .Air Sparge. Ozone) ❑ HAND AUGER <br />_❑ OTHER: <br />❑ OTHER: <br />SEP 2 8 2012 <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 1.5 inch ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS NA TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />DEPTH OF GROUT SEAL 8 feet TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />GROUT SEAL PUMPED: ❑ Yes In No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />GROUT SPECIFICATIONS Portland <br />APPROX. BORING DEPTH 8 feet ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />CONDUCTOR CASING ® No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: <br />COMMENTS: Work performed for in-place abandonment of diesel UST piping. <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 (23 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, ani appli9ftk}19-G9 ifprnia I@ws. <br />Signed _ <br />Print Name <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS <br />WORK PLAN DATED <br />APPLICATION ACCEPTED BY DATE ISSUED <br />GROUT INSPECTION BYE ° FINAL INSPECTION BY <br />DESTRUCTION INSPECTI BY DATE <br />COMMENTS/CONDITIONS: <br />AREA <br />DATE <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D B <br />DATE <br />SERVICE <br />I RO # <br />INVOICE <br />REQUEST <br />PR # <br />$125x <br />i <br />SR# 0 [),&,�'711 <br />RO # <br />(3500) <br />PR # <br />(2900) <br />C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />EHD 29-01 01/13/12 WELL PERMIT APP <br />