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C-57 Contractor Advanced GeoEnv. <br /> <br />Consultant/Sub CntAdvanced GeoEnv. <br />Billable Party Wiley Chandler <br />GIS Coordinates: X <br />aL( !News <br />erIA. <br />DATE <br />/z//7-ito <br />SERVICE RO # <br />REQUEST PR # <br />sR# 664 <br />RO # <br />pm) <br />INVOICE <br />PR # <br />(2900) <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468 -3454 Fax: (209) 468 -3433 Web: www.s <br />WELL & BORING PERMIT APPLICATION <br />LOP <br />SITE MITIGATION <br />UNIT IV <br />Cal/ED <br />ov.or <br />FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIMN <br />1 6 2010 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 applicatiENWffisi <br />Joaquin County Development Title,'Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Dep <br />Waterloo Stockton Cross Street City Zip 95215 <br />Address P. 0. Box 507 City Stockton Zip 95207 <br />Address 837 Shaw Road City Stockton Lic 680227 <br />Address 837 Shaw Road City Stockton Lic 680227 <br />Address P.O. Box 507 City Stockton Zip 95270 <br />CONSTRUCTION WORK TO BE PERFORMED: <br />Fg NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) <br />0 SOIL BORING IDs 7- soil Borings 4- 2. wt. encl_k_ <br />El WELL IDs <br />0 OTHER IDs <br />TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING D HOLLOW STEM DIA. OF BOREHOLE 1.25-incf1=1 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA, <br />0 EXTRACTION: Vapor/ Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL 0 PVC 0 OTHER <br />D SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL Entire TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE KPIPE <br />SOIL BORING 121 PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: 0 Yes 0 No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />0 INJECTION (Le .Air Spame Ozone! 0 HAND AUGER GROUT SPECIFICATIONS 94 lb bag of Portland + not more than 6 gallons of water <br />0 OTHER: 0 OTHER: APPROX. BORING DEPTH 5 and 80 feet 0 BOLTED TRAFFIC BOX OR 1:1 STOVE PIPE <br />CONDUCTOR CASING 0 No 0 Yes: Casing Dia: Casing Depth: Boring Dia: <br />COMMENTS: <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />Site 'Location PITON. Wilcox <br />Property Owner Wiley Chandler Phone <br />Phone <br />Phone <br />Phone <br /> <br />800 511-9300 <br /> <br />800 511-9300 <br /> <br />,wcr_ipliance with San <br />cni (AL HEALTH ISr-• - <br />APN <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> # OF WELL(S) TO BE DESTROYED El OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br />WELL IDs: El PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br />GROUT SPECIFICATIONS p EXPLOSIVES FROM TO FT BELOW SURFACE <br />TREMIE TYPE TO BE USED: 1:1AUGERS 0 HOSE Cl PIPE <br /> <br />CI 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 prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and all appli le Califo ia laws. <br />Signed Title/Company (tj1071e(..,"\-- 6e0)(),(5-t )AaiLic,ned 6e€1, <br />Print Name -)fik Cin 1A1111414-1;1 Date JD-- / <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS 1.3 15 0 A). <br />WORK PLAN DATED 12-11(01LO <br />APPLICATION ACCEPTED BY DATE ISSUED t2.f Ir f 1AREA <br />GROUT INSPECTION BY t f sii/ FINAL INSPECTION BY DATE <br />DESTRUCTION INSPECTION BY DATE <br />COMMENTS/CONDITIONS: <br />ACCOUNTING ONLY: AID # <br />PE CODES FEE INFO AMT REMITTED <br />$ 122 x I. 4s 1 2- 2.--c.0 <br />VI 0 5 366— vo <br />C-57 WC <br /> <br />WAIVER <br /> <br />C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br /> <br />ENCROACHMENT DOC <br />WELL PERMIT APP EHD 29-01 07/28/10 <br />