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gDtrr. SAN JOAQUIN COUNTY r--? <br /> a ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siaov.ora/eh UNIT IV <br /> ��lFOR <br /> WELL & BORING PERMIT APPLICATION NOV $ 4 2014 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,ENv'IR ! ' FS,LTI <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 S660ES <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> �2? Rt' h4 of 1,Jay <br /> Property Site Location <br /> o $MLK{er �tltiS1�s Street N Center Street City/State Stockton Zip 95204 APN City of Sloe ton <br /> —q rviz­ <br /> Owner -Afte& Address t�y-a 2FiZ l Jal S�44 ( <br /> City/State •6eR-ReRaerl Zip Phone 925 2;6 8897- <br /> C-57 Contractor Cascade Drilling Address 3000 Duluth St. city/State Wes,Sacmmenlo Lic 938110 Phone 916-638-1169 <br /> Consultant/Sub Cntr,pQiAddress8 CWTA4&W4�. Sur7a'G. City/State V"JV'44J4Lic Phone <br /> Billable Party 14T71A4"e RCN '�&b Address / O BOJ 1 25? City/State 5j Amo izip C ` 3 Phone 9:t5• - 3,30 <br /> GIS Coordinates:X 3047`o Y -tZ/.Z9%o <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> 0 OTHERIDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _0 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 /> _0 SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION(i.e ArSearoe Ozone)O HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: 0 OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING 0 No 0 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,(CHECKALLTHAT APPLY) <br /> _13_#OF WELL(S)TO BE DESTROYED ■OVER-BORE DIAMETER OF INCHESTO DEPTH OF To FT <br /> WELL IDs: See attached 0 PRESSURE GROUT TO DEPTH OF TOTAL DEPTH FT BELOW SURFACE <br /> GROUTS PECI FICATIONS 6GALOFWATER:ONE94LBSACKOFPORTLANDCEMENT ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE a PIPE MUSHROOM CAP AT(>3 FT) 3 FT BELOW SURFACE <br /> COMMENTS SEE ATTACHED FOR DIAMETER AND DEPTH INFORMATION <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 California laws. <br /> Signed Irtad.Aer ' / Title/Company PROJECT MANAGER/BROADBENT&ASSOCIATES <br /> Print Name JASON DUDA Date 11-2.0-1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS IL 6- /*9IL?.tDmz& Wj±W t S Y 'r'TON <br /> WORK PLAN DATED Alke C /O 1 go/5/ <br /> APPLICATION ACCEPTED BY ..�. �r,D l'3'iCK� DATEISSUED AREA /G 79 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COM ME NTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SRERVICE RO INVOICE <br /> EQUEST PR: <br /> 35bZ $ 130x a3 o Sot2 0- uWN Lc _¢ SR# <br /> 3503 3 a RO# <br /> (3500) <br /> PR# <br /> (2900) <br /> C-57 1L- WC WAIVER� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT I," ENCROACHMENT DOC <br /> EHD 2M1 7/24/14 WELL PERMIT APP <br />