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s P✓ <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 Hazefton Avenue, Stockton, CA 95205-M2 <br />Telepe. (209) 468-3147 Fax. (209) 468-3433 Web: wwwsj-qov.orqtehd <br />hon <br />LOP <br />SITE;WN <br />WELL & BORING PERMIT APPLICATION lizu <br />FOR WELLS AND BoRiNes USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION APR <br />W <br />NQN-REFUNDABLE POMIT EXPIRES 1 YEAR FROM DATE ISSUED JOAQUfIV <br />C <br />Application 13 hereby made to Son Joaquin County for a permit to construct and/or Instati the work described. This application is made <br />Joaquin County Development Title, Chapter 9-1115.3. and the Standards of the San Joaquin County Environmental HealthDepartment". ;-EEPAR <br />t <br />Edi <br />Site Location 17100 Murphy Parkway Cross Street D:Parkway Laffiop, CA "CyZAPN j 12009 <br />Property ZZZL� �I' —k-taptcl 1"0 <br />Owner ASP/RWM Properties, et al Address Aloe Ste Cily/State4eP9otxVCA Phone (22fi) ffA=9A00 <br />C-57 Contractor Cascade Drilling _ Address 3000 Duluth Street City/State West Sac.. Ckjc 938110 Phone (916) 638-1169 <br />ConsuftanVSub Cntr Brusca Assoc., Inc, Address PO Box 332 CftyjState Roseville, CAUC CEG#1948_ phone (916)677-1470 <br />�Billable Party B-sm Assoc., Inc- Address PO Box 332 CjhpS-tateRosevIlle.CAZjp­L56 �lphong(916)677-1470 <br />GIS Coordinates: X 37-806 y -121.287 FZOSCA� 4910— - tG. :7 5 S-?o('*1SZ1?t9POD <br />-• PO— 04AZOF-,:�� <br />- gk _. - <br />0 WELL IDs <br />n OTHER <br />TYPE A A OE WE11.118ORM L4§jN.LAMN T—YPF. CWSTRIUCTIQN SPF-CIEtg&jM§ <br />—0 MONITORING 0 HOLLOW STEM Dtilk OF BOREHOLE 2' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:- <br />--J:l EXTRACTION: Vapod Water 0 HAMMERIDRIVEN CASING THICKNESS —_TYPE OF CASING* 0 STEEL 0 PVC 0 OTHER <br />—0 SOIL VAPOR PROBE E3 MUD ROTARY 09" OF GROUT SEAL_TREMIE TYPE TO BE USED: [3AUGER3 [3HOSE OPIPE <br />.Lei SOIL BORING [3 PUSH POINT (GPI CPT) GROUT SEAL PUMPED. D Yes [I No (MAXIMUM FREE FALL DEPTH is 30 FT) <br />_O INJECTION &e.Air&ww Dmrwl [3 HAND AUGER GROUT SPECtFlCATIONS Boreholes to be completed grouted with nest cement <br />—0 OTHERz- 0 OTHER: APPROX BORING DEPTH 15, 0 BOLTED TRAFFIC BOX Oft 0 STOVE PIPE <br />COLIMENTS: Direct push borings CONDUCTOR CASING 0 No 0 Vow Caming Dia: _Casing Depth: _ Bering Dia: <br />--_-#OF'11S1.L(S)TOBE DESTROYED 0 OVER -BORE DIAMETER oF____pr-HFs TO Do" o <br />WELL lDs: 0 PRESSURE GROUT -to DEPTH OF FT BE S <br />GROUT SPECIFICATIONS 13 EXPLOSIVES FROM _____YO _____FT MOW SURFAC! <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE 0 MUSHROOM CAP AT (>3 BELOW SURF <br />cm, ITTIRITS <br />5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />I hereby certify " I have prepared this application and that the work will be done In accordance with San Joaquin County Orclirtances, Rulm and <br />Regulations, anolgli appr0able Califorrilat kwsL <br />Signed <br />Print Name JOV <br />Title/Company President! Brusca Associates. Inc. <br />[)ate 3127/17 <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS <br />WORK PLAN DATED <br />APPLICATION ACCEPTED BY ixmissum dult7- —AREA <br />GROUT INSPECTION BY FINAL INSPECTION BY DATE <br />DESTRUCTION INSPECTION BY <br />C-57— TIC —WAIVER _ C-57 LETTER OF AuTHORIZATION To SIGN PERMIT OACHMENTDOC— <br />EHDZ"1 3109M WELL PERMIT APF <br />