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Rv� <br /> • PW <br /> oPqul SAN JOAQUIN COUNTY • CO) <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> <<FORra. Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.siclov.oro/eh UNIT IV <br /> WELL & BORING PERMIT APPLICATION h,'Ob' <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 /> L�Is RI' h4 of tJay RotJ <br /> Site Location l C S4»L.1 yy� `i6.a s Street N Center Street City/State Stockton 95204 <br /> Property st Zip APN City of Stockton <br /> Owner -ARe& Address N ZR,9—f3 A42"( panuru ¢. S}nc.K I.y. <br /> City/State San-Berrien Zip 94585Phone 926 a;45 <br /> C-57 Contractor Cascade Drilling Address 3000 Duluth St. City/State Wee)Seaamento Lic 938110 Phone 916-638-1169 <br /> Consultant/Sub Cntr30,0ADS4-4f_y-e65iV Address8 00777Ats NAS$u17EG City/State U"1P4e44J4Lic Phone <br /> Billable Party /47KAbriC RCN J b Address P-0 BOA ) 25-P City/State SNN AW-wip91!9R3 Phone ;> <br /> GIS Coordinates:X 3D,5479; Y -rzt,79%o <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _O EXTRACTION:Vapod Water Cl HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE [I PIPE <br /> _0 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION if a.Air Soame.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> -0 OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING[INo[IYes:Casing Dia: Casing Depth: Boring Dla: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> 23 #OFWELL(S)TOBE DESTROYED DOVER-BORE DIAMETER OF INCHES TO DEPTH OF To FT <br /> WELL IDs: See attached ®PRESSURE GROUT TO DEPTH OF TOTAL DEPTH FT BELOW SURFACE <br /> GROUTSPECIFICATIONS 6GALOFWATER:ONE 94 LB SACK OF PORTLAND CEMENT ❑EXPLOSIVES FROMTO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:[IAUGERS EJHOSE ® PIPE E MUSHROOM CAP qT L3 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 Californial/ �laws. <br /> Signed AhO2, 'x 4J Title/Company PROJECT MANAGER/BROADBENT&ASSOCIATES <br /> Print Name JASON DUDA Date 11-2-0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS IG C• /•1/d1217uVG &)&j S 7b0K704-' <br /> WORK PLAN DATED 191492// /O ) <br /> APPLICATION ACCEPTED BY J. 1 cDA•cKM DATE ISSUED /2.3-rC( AREA /G <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY; AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 35x2 <br /> $ ,3DXa3 o S 2 �vuv7�2 _¢ sR# ?/d8S <br /> 35030 -sic) (3o0 <br /> PR# <br /> (2900) <br /> C-57 rL WC _WAIVER K­J4 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC <br /> EHD 29-01 7/24/14 WELL PERMIT APP <br />