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Some � <br /> A4�1" SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> ' ":'• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> " •.joN:P Telephone: (209) 468-3147 Fax:(209) 468-3433 Web: wWW.siaov.orglehd UNIT IV <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> r <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 /> N Site Location 2908 W.Benjamin Holt Dr Cross Street Plymouth Road City/State Stockton,CA Zip 95207 APN Caltrans ROW <br /> Property <br /> t <br /> Owner City of Stockton-Caltrans Address 425 N.EI Dorado Street City/State Stockton,CA Zip 95202 Phone <br /> C-57 Contractor National EWP Address 14110 Cacheville Road City/State Yolo,CA Lie 953646 Phone 530-419-7300 <br /> Consultant/Sub Cntr Stantec Consulting Address 3017 Kilgore Road,Suite 100 City/State Rancho Lie 95670 Phone 916-861-0400 <br /> Services,Inc. Cordova,CA <br /> 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&#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 kir Soarce.Ozones❑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: CHECK ALL THAT APPLY <br /> 1 #OF ELLS TQ BE DESTROYED m OVER-BORE DIAMETER(see wen oeswctgn oetaits Tawe) <br /> WELL ID .anw-s / ❑PRESSURE GROUT To DEPTH OF FT BELow SURFACE <br /> GROUTS ECIFIC TONS Neat Cement er SJDEH Guidelines ❑EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:'AUGERS ❑HOSE PIPE ❑MUSHROOM CAP AT(>3 FT} FT BELOW SURFACE <br /> COMMENTS <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,aq all applicable California laws. <br /> Signed r41�!t Title/Company Senior Geoloqist Stantec <br /> Print Name Shane Olton Date 71 P� to <br /> pDEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS- <br /> WORK <br /> DDRESS WORK PLAN DATED <br /> APPLICATION ACCEPTED DATE ISSUED��?��D/� AREA <br /> 1 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 /> p G REQUEST PR# <br /> SOa $125. �/7� O •��' '�o'j SR#Q ,,7,� <br /> 3;5 3,;j2 -00 �7 >/ /,3 Roo �o <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC s-' <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />