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Y <br /> SAN JOAQUIN COUNTY <br /> a DEPARTMENT <br /> ENVIRONMENTAL HEALTH DEPAR <br /> <: LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232. SITE MITIGATION <br /> �da�� FOR •° Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.sm_gov.org/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 De v lopment Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Heals Department. <br /> I low 5F. <br /> L <br /> Site Location-'�-E-µeFdiB�Wey , dross Street N Center Street City/State Stockton Zip '9526 APN 139-020-03 <br /> Property Wei xww3ePa--^T- <br /> 5(&4 S1I pp <br /> Owner A9,60 Address P.O.Box 3457 City/State *6any4mnon Zip Phone 925-275-3807 <br /> C-57 Contractor Cascade Drilling Address 3000 Duluth St. City/State West Sacramento Lic 938110 Phone 916-638-1169 <br /> Consultant/Sub Cntr A1?SRD,6kA)T-+Address 8XQO'Mr AAAA 5¢rr4, cS. City/State two Lic Phone QZS•1�} 3$OZ <br /> Billable Party AT4pNT1C R<4*,' ri ,bd:>Address PO BOX 1157 City/State S� K**Wip 99S83 Phorle?LS- .275. 3880? <br /> GIS Coordinates:X 37.9467q Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE [I PIPE <br /> _E]SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.Air Soame Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _O OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD•(CHECK ALL THAT APPLY) <br /> --L_#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: MW-8 9 PRESSURE GROUT TO DEPTH OF 40.5 FT BELOW SURFACE <br /> GROUT SPECIFICATIONS 6 GAL OF WATER:ONE 94 LB SACK OF PORTLAND CEMENT ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE V PIPE E MUSHROOM CAP AT(>3 <br /> COMMENTS FT) 3 FT BELOW SURFACE <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 applicable CCaliforn/ia la/wns., <br /> Signed '�1�Y �A,�IMMA� Title/Company PROJECT MANAGER/BROADBENT&ASSOCIATES <br /> Print Name JASON DUDA <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 16 f• /dlQef)twee, W/'eLc� / 37M4<X�.J <br /> WORK PLAN DATED M 091 N IO I <br /> APPLICATION ACCEPTED BY ri•`�'�l9,fK m DATE ISSUED 12-Z-14.` AREA /6 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COM ME NTSICON DITI O N S: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> REQUEST PR# <br /> 35Uz s130x O Sg20 Cc'CcWT< SR# 1/063 <br /> 390 RO# <br /> 3500 <br /> PR# <br /> (2900 <br /> C-57 V WC ✓ WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT 1/ ENCROACHMENT DOC,.f✓� <br /> EHD 29-01 7/24/14 WELL PERMIT APP <br />