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oR�`�`'19 •.F - SAN JOAQUIN COUNTY <br /> ORIGINAL <br /> % ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone: 209 468-3147 Fax: 209 468-3433 Web:www.sigov.org/ehd 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 Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 290SW.Benjamin Holt Dr Cross Street Plymouth Road City/State Stockton,CA Zip 95207 APN City ROW <br /> Property <br /> Owner City of Stockton-Swenson Park Golf Course Address 425 N. <br /> EI Dorado/Street City/State Stockton,CA Zip 95202 Phone <br /> _ <br /> C-57 Contractor br,6jiDrill Iln Address47j9D *rGWe- faaA City/Statepilllr-} Mild_ Lic.y$51K PhoneQjgff)313'54W <br /> Consultant/Sub Cntr Stantec Consulting Address 3017 Kilgore Road,Suite 100 City/State Rancho Lic 95670 Phone 916-861-0400 <br /> Sordova,CA <br /> Services,Inc.Inc.Billable Party(consultant) Address City/State Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE 8r#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.Air Soarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECKALL THAT APPLY) <br /> #OF WELL(S)TO BE`rF�SpY 4sj OVER-BORE DIAMETER(see Well Destruction Details Table) <br /> EA _ <br /> LL IDs:Mw-s,MW-e �/ (fl PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Neat Cement per SJDEH Guidelines EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPEA0 BE USED:R AUGERS ❑ HOSE 34 PIP MUSHRQOM CAP AT(�3rFT) FT BELOW SURFACE <br /> COMMENTS W'Sa ,0jS— UIr�/Nl1$1'�75 - <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 a plicable California laws. <br /> Signed Title/Company Senior Geologist Stantec <br /> Print Name Shane Olton Date f gc'i'- <br /> DEPARTMENT USE ONLY /f <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS9Q5 <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY E I 3 ( REA 9 <br /> GROUT INSPECTION BY FINAL INSPECTION BY p4:gA QATE <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 /> •� Q REQUEST PR# <br /> 3�0 $125 x a /���� %/� SR#00i 5 <br /> o 7-f 00 7�Ti�,3 7�// s 00 <br /> 2,,oZ ��z5,xi Z�: 39�?�H /� // 290U <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />