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SAN JOAQUIN COUNTY • FILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATI N <br /> Telephone: 209 468-3147 Fax: 209 468-3433 Web:www.sigov.org/ehd 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 mode to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with n <br /> Joaquin Countylo ell?,pc way orale Chapter) e 1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location east of 112 Rose Lane Cross Street _Yosemite Avenue - city/State Manteca/CALp 95335 APN n <br /> Property City of Manteca 1001 W.Center Street <br /> Owner Address City/State MantecalCAZip 95337 Phone (209)456-85845 <br /> C-57 Contractor Gregg Drilling Address 950 Howe Street Ci IState A48rtInez/C <br /> ry pLic 485165 Phone(925)313-580 <br /> Consultant/Sub Cntr Ami Adinl&Assoc. Address 4130 Cahuenga Blvd., Ste 113 City/State Los Angelekl�A Phone IS'6)824 $10 <br /> Billable Party Aml Adini&Assoc.. Inc. Address 4130 Cahuenga Blvd., Ste 113 CirytState Los Angela zip 91602 Phone(818)824-81 - J <br /> GIS Coordinates:X 37.797953 y-121.222695 CA <br /> Latitude Longitude T_ <br /> CONSTRUCTION WORK TO BE PERFORMED- <br /> E] NEW WELLIBORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHERI <br /> ❑ SOIL BORING IDs <br /> IT]WELL IDs MW15A& MW155(SDlit QWM wells) <br /> ❑ OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _© MONITORING IN HOLLOW STEM DIA.OF BOREHOLE 10„ ❑MULTIPLE CASINGS 0 MULTI-LEVELWELL CASING DIA: I <br /> _❑EXTRACTION:Vapor!Water 0 HAMMER/DRIVEN CASING THICKNESS Schedule 40,SPE OF CASING: O STEEL M 2PVC ❑ OTHER ---?— <br /> _❑SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL 5'Annular)`TEEMIE TYPE TO BE USED: ®AUGERS []HOSE l]14`FE <br /> _0 SOIL BORING 0 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes E3 No(MAXIMUM FREE FALL DEPTH IS 30 FT) t' <br /> _I] INJECTION(i.e NT$Dame.Ozone)0 HAND AUGER GROUT SPECIFICATIONS Bentonite cement slurry <br /> _O OTHER: 0 OTHER: APPROX.BORING DEPTH MWI5A:3P;MW158:70' [3 BOLTED TRAFFIC BOX OR 0 STOVE' <br /> CONDUCTOR CASING N No❑Yes:Casing Dla: Casing Depth:_ Boring Die: I <br /> COMMENTS:Well construction per attached Well Construction Dia ram. <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:r H <ALL THAT APP Y) <br /> _-OF WELL(S)TO BE DESTROYED El OVER-BORE DIAMETER OF INCHES TO DEPTH OF�rr <br /> WELL IDS: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SUR <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURPtte <br /> TREM;E TYPE TO BE USED:❑AUGERS ❑ HOSE ❑PIPE ❑MUSHROOM CAP AT(g3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS - <br /> I hereby certify that have ryypared this a p7i atlon and that the work will be done In accordance with San Joaquin County Ordinances, Rulec_atsd <br /> Regulations,an a N . E1a Cali <br /> SIGN HERE <br /> Signed �j <br /> * lI Title/Company <br /> Print Name r <br /> DEPARTMENT USE ONLY <br /> SITE h1AP IN UNIT IV FILE-SITE ADDRESS V0509r'r r7iE 19 UE 11*9/U7E24 <br /> WORK PLAN DATED /1469 <br /> APPLICATION ACCEPTED BY DAKE ISSUED R-q-1 AREA. IG cI_9_=. <br /> GRGUT INSPECTION 6Y FINA DATE I•t 1,_-° <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# - --- <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SRERVIEQUEST PCE RR#O# INVOII!e' <br /> C) f S 125x 7-Zy-15 'isR# <br /> RO# <br /> 3500) <br /> PR# <br /> 2900 <br /> C-;7—I/ WC _WAIVER rA-s-7� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC, a <br /> EHD 29-0 M09;12 WELL PERMIT APP <br />