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30k4 <br />IRAW <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />ORIGINAL <br />LOP <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br />Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.ort7/eh 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 6455 Pacific Ave Cross Street West Benjamin Holt <br />Property <br />Owner F.'M8'MFN pnne,LLC�L.,D'Am arwtlsaM&sgeo-d Address 2500 Ventura Oaks Way <br />C-57 Contractor National E.W.P Address 1961 Meeker Ave <br />ConsultanVSub Cntr Address <br />Billable Party Geosyntec Consultants Address 3042 Gold Canal Drive Suite 201 <br />GIS Coordinates: X 121.321172° W Y 38.008905° N <br />❑ NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) <br />City/State Stockton, CA Zip 95207 APN09741029 <br />City/State Sacramento, CA Zip 95333 Phone 916-646-8211 <br />City/State Richmond. CA LIC 953646 Phone 510-236-6282 <br />City/State Lic _ Phone <br />City/State een hoCorOo a `" zip 95670 Phone 916-637-8048 <br />❑ SOIL BORING IDS <br />AID # <br />❑ WELL IDs <br />PE CODES <br />❑ OTHER IDs <br />AMT REMITTED CHECK # <br />TYPE & # OF WELL/BORING INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />_❑ MONITORING ❑ HOLLOW STEM <br />DIA OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br />_i] EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />_❑ SOIL VAPOR PROBE ❑ MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />_❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) <br />GROUT SEAL PUMPED: ❑ Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />_❑ INJECTION (i-e.Air Sparge. Ozone) ❑ HAND AUGER <br />GROUT SPECIFICATIONS <br />_❑ OTHER: ❑ OTHER: <br />APPROX. BORING DEPTH ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />CONDUCTOR CASING ❑ No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: <br />COMMENTS: <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />DESTRUCTION WORK TO BE PERFORMED: <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />z # OF WELL(S) TO BE DESTROYED <br />0 OVER -BORE DIAMETER OF see table INCHES TO DEPTH OF Sae Tabie FT <br />WELL IDS: SVE-033 and SVE-032 <br />© PRESSURE GROUT TO DEPTH OF See Table FT BELOW SURFACE <br />GROUT SPECIFICATIONS Neat Cement(941bbag/ 5.6gallons waler <br />EXPLOSIVES FROM TO FT BELOW SURFACE <br />TREMIE TYPE TO BE USED: ❑N AUGERS ❑ HOSE ❑ PIPE <br />© MUSHROOM CAP AT (?3 FT) 3 FT BELOW SURFACE <br />COMMENTS Tables, figures, access agreement and data for pressure grouting attached <br />5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />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 />all a /Ilcablw California laws. <br />Re ulations, a�p <br />Signed /ifiL�L G Z <br />Title/Company Project Geologist 1167 it o Sy n I! r <br />Print Name Timothy Davis <br />Date 8/2212014 <br />T USE ONLY <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS 1-mlive #Ly b1'::'4 <br />WORK PLAN DATED 1j t / <br />APPLICATION ACCEPTED BY J, 101gku 0e1 DATE ISSUED AREA � <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />COMMENTS/CONDITIONS: <br />FINAL INSPECTION BY <br />DATE <br />DATE <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED CHECK # <br />RECV'D BY <br />DATE <br />SERVICE <br />REQUEST <br />RO # INVOICE <br />PR# <br />OZ <br />$130 x <br />2233 S. <br />601wa <br />v'Z'Z lel <br />SR# W 70 38 <br />q <br />d1 <br />'3?0RO <br /># <br />3500 <br />PR # <br />(2900) <br />C-57 V WC V WAIVER ^AZJI== C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ` ENCROACHMENT DOC_ "M <br />EHD 29-01 7/24/14 T WELL PERMIT APP <br />