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'a`''� c SAN JOAQUIN COUN1`P' <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> • 600 East Main Street, Stockton,CA 95202-3029 SITE MITIGATION <br /> T61eph6n6. (209)468-3147 Fax. (209)468-3433 Web:www.sigov.org/eh UNIT IV <br /> / NOV 13 2013 WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> ENVIRONMENTRAI,HESLTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applica�r✓elrt�ae 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 3012 E WaterlooaCads street N Golden Gate Ave city Stockton Zip 95204 APN 143-130-24 <br /> Property Vincent Hernandez 4302 Bolder Creek <br /> Owner Address City Stockton zip 95219 Phone 477-4362 <br /> C-57 Contractor All Well Abnmt Address 9245 Beatty Drive city Sacramento Lic 848359 Phone 916-363-well <br /> Consultant/SubCntr AGE Address 837 Shaw Road cltyStockton Li, 680227 Phone209-467-1006 <br /> Billable Party AGE Address 837 Shaw Road city Stockton zip 95215 Phone�Oq-46 -1 nnR <br /> GIS Coordinates:X �t Y_"*/2 I� e <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT.GEOPROSE,HYOROPUNCH,HAND-AUGER,OTHER) <br /> 0 SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _0 MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING D1A: <br /> ,_❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS ❑HOSE ❑PIPE <br /> —0 SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION t1.e AAIr&A a.OMM❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX..OR 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING(3No[IYes:Casing Dia: Casing Depth: Boring Dia: <br /> NOTE: OFFSITE WELLS.B BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: Ec THAT APP <br /> #OF WELLS)T BE DESTROYED OVER-BORE DIAMETER OF - INCHES TO DEPTH OF 70 FT <br /> WELL IDs: W-1 TO MW-3 ❑PRESSURE GROUT TO DEPTH of FT BELOW SURFACE <br /> GROUT SPECIFICATIONS 0 EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:13 AUGERS ❑HOSE ❑PIPE Q MUSHROOM CAP AT(?3 Fr)-' FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have pr%pared this app!catio and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all appiic b California la <br /> Signed r+�-1 Title/Company Geologist/AGE <br /> Print Name �►► ,IIISm-laittle Date /11/13 <br /> DEPARTMENT USE ONLY <br /> SITE MAP 1N UNIT IV FILE-SITE ADDRESS 3/t�z LkXgZ� P,JS�iMO) <br /> WORKPLAN DATED It6-61c cz: 11-101S_ <br /> APPLICATION ACCEPTED BY J- ,!O ra-t&4 +y DATE ISSUED AREA / <br /> GROUT INSPECTION BY FINAL INSPECTION 13Y DATE <br /> DESTRUCTION INSPECTION BY DATE. <br /> COMM ENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 35OZ $125X v 3v3� Cou r //-�3-/3 SR# <br /> 3 50- 3 3 95 RO# <br /> 3500 <br /> PR# <br /> 2800 <br /> C-57 r/ WG WAIVERC-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENGROACHMENT DOC X/t�. <br /> EHD 29 01 01H3/7Z ✓ WELL PERMIT APP <br />