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�� <br />s1R <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />LOP <br />i 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE NIT IVTIpN <br />U <br />w. <br />Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: wwsilUov.orgleh UNIT V <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 374 Lincoln Center <br />Property <br />Owner I ncdn Propn,llxs LTD clo Sim,-G�pe MgW Corp <br />C-57 Contractor National E.W.P <br />Consultant/Sub Cntr <br />Billable Party Geosyntec Consultants <br />GIS Coordinates:X 121.321172° W <br />Cross Street West Benjamin Holt <br />Address 374 Lincoln Center <br />Address 1961 Meeker Ave <br />Address <br />Address 3042 Gold Canal Drive Suite 201 <br />8.008905° N <br />X71 <br />City/State Stockton, CA Zip 95207 APN(;N741029 <br />City/State Stockton, CACA Zip 95207 Phone 209-478-9200 <br />City/State Richmond, CA Lic 953646 Phone 510-236-6282 <br />City/State Lic _ Phone <br />City/State Rancho6—Titles CN Zip 95670 Phone 916-637-8048 <br />❑ NEW WELUBORING (CPT. GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) <br />❑ SOIL BORING IDs <br />FAC # <br />PE CODES <br />❑ WELL IDs <br />AMT REMITTED <br />CHECK # <br />❑ OTHER IDS <br />DATE <br />SERVICE <br />REQUEST <br />TYPE & # OF WELL/BORING <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />_❑ MONITORING <br />Q HOLLOW STEM <br />DIA OF BOREHOLE Q MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br />_❑ EXTRACTION: Vapor/ Water <br />❑ HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC Q OTHER <br />_❑ SOIL VAPOR PROBE <br />❑ MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />_❑ SOIL BORING <br />❑ PUSH POINT (GP/ CPT) <br />GROUT SEAL PUMPED: ❑ Yes Q No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />_❑ INJECTION (_e.Air Saarae Ozone) ❑ HAND AUGER <br />GROUT SPECIFICATIONS <br />❑ OTHER: <br />❑ OTHER: <br />APPROX BORING DEPTH ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />CONDUCTOR CASING ❑ No Q Yes: Casing Dia: Casing Depth: _ Boring Dia: <br />CO <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />ez # OF WELL(S) TO BE DESTROYED ® OVER -BORE DIAMETER OF Sas Tame INCHES TO DEPTH OF See Table FT <br />WELL IDS: See Tabh, ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br />GROUT SPECIFICATIONS Neat Cemet(94lbbag/ 5.6gallons walor ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br />TREMIE TYPE TO BE USED:❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT (>3 AT FT BELOW SURFACE <br />COMMENTS Tables figures access agreement attached <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, a d all applicable California laws. / <br />Signed L/_7�- Title/Company Project Geologist /Cir <<�y� fe c <br />Print Name Timothy Davis Date 8/22/2014 <br />SITE MAP IN UNIT IV FILE - SITE <br />WORK PLAN DATED <br />APPLICATION ACCEPTED BY _ <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />COMMENTS/CONDITIONS: <br />DEPARTMENT USE ONLY <br />rF10- d- &W HA4-r 74?<*T0A✓ <br />E <br />DATEISSUED <br />FINAL INSPECTION BY <br />DATE <br />114 ARFA 1111 <br />DATE <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE <br />SERVICE <br />REQUEST <br />I RO # <br />PR# <br />INVOICE <br />ago <br />S 130 x <br />,iXOGO <br />22335 Z <br />&kWW, <br />SR# �b 38 3 <br />;gO3 <br />3 o <br />3C70 <br />3500 <br />PR # <br />2900 <br />C-57 V WC ✓ WAIVER rr C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOCS <br />EHD 29-01 7/24/14 WELL PERMIT APP <br />