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TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> # OF WELL(S) TO BE DESTROYED <br /> <br />0 OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br />WELL IDs: 0 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br />GROUT SPECIFICATIONS 0 EXPLOSIVES FROM TO FT BELOW SURFACE <br />0 MUSHROOM CAP AT (.3 FT) FT BELOW SURFACE <br />APPLICATION ACCEPTED BY J. je Iffiryj <br />DATE <br />GROUT INSPECTION BY FINAL INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />COMMENTS <br />QUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />ation and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br />s. <br />Title/Company Sr. Geologist/Gribi Associates <br /> Date 81 I <br />5 WORKING DAYS NOTICE <br />I hereby certify th I have prep <br />Regulations, andj applicabl <br />Signed <br />Print Name James E. Gribi <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE SITE ADDRESS 3 3 t o e . m_' 54_r • 5 kxf x-ro ,t) <br />WORK PLAN DATED 8-46- <br />DATE.IS AREA 6Q?‘ <br />ATEtZt1CX• <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East HazeIton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sjqov.orgiehd <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 />3310 & 3330 E. Main St. <br />Site Location Cross Street S. Netherton Ave. City Stockton zip 95205 APN 157-110-01 <br />Property 43385 Business Park Dr . EH National Bank Owner Address Suite 200 <br />, <br />City Temecula zip 92590 <br />C-57 Contractor Gregg Drilling Address 950 Howe Road City Martinez Lic 485165 P e 99 5212 7 313508070 Phone 513312 <br />Consultant/Sub CntrGribi Associates Address 1090 Adams St. City Benicia Lic NA Phone 707 -748 -7743 <br />Billable Party Gribi Associates Address 1090 Adams St. City _ Benicia Zip 94510 Phone 707 -748-7743 <br />GIS Coordinates: X <br />CONSTRUCTION WORK TO BE PERFORMED: <br />[2:1 NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) <br />E] SOIL BORING IDs B-1, B-2, B-3, & B-4 <br />D WELL IDs <br />0 OTHER IDs <br />TYPE & # OF WELL/BORING <br />0 MONITORING <br />INSTALLATION TYPE <br />0 HOLLOW STEM <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2 " 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />13 EXTRACTION: Vapor/ Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />4 ED SOIL BORING rn PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: 0 Yes 0 No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />El INJECTION (i.e .Air Spam. Ozone). 0 HAND AUGER GROUT SPECIFICATIONS PE.PAT CE-14461QT - ivo i3eiu-to,v(74 <br />APPROX. BORING DEPTH ?,(-)' 0 BOLTED TRAFFIC BOX OR 0 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 />COMMENTS/CONDITIONS: <br />ACCOUNTING ONLY: AID # FAC # <br />PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE <br />REQUEST <br />RO # <br />PR # INVOICE <br />M C $ 125 x I 5--- ,5‘3ce e_rp 8-(7-(7 SR# 61-526 <br />2-90°) -75--- <br />i> <br />RO # <br />(3500) <br />PR # <br />(2900) <br /> WAIVER 1t7 fi- C57 LETTER OF AUTHORIZATION TO SIGN PERMIT V. ENCROACHMENT DOC 4,4 <br />FILE CrIPY <br />LOP <br />SITE MITIGATION <br />UNIT IV <br />0 OTHER: 0 OTHER: <br />C-57 WC