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4"I SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> W: <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> •. :� <br /> Telephone: 209 468-3147 Fax: 209 468-3433 Web:www.sogov.org/ehd UNIT IV <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> f 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 2908 W.Benjamin Holt Dr Cross Street Plymouth Road City/State Stockton,CA Zip 95207 APN 097-630-10 <br /> Property <br /> Owner Aileen Boland Address 6621 Plymouth Road City/State Stockton,CA Zip 95207 Phone <br /> C-57 Contractor National EWP Address 14110 Cacheville Road City/State Yolo,CA Lic 953646 Phone 530-419-7300 <br /> Consultant/Sub Cntr Stantec Consulting Address 3017 Kilgore Road,Suite 100 City/State Rancho Lic 95670 Phone 916-861-0400 <br /> Billable Party tcoesunantpervices,Inc. Address City/State ordova,CA 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 /> I ❑OTHER IDs <br /> TYPE&#OF WELUBORING 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 a.Ajr 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: CHECK ALL THAT APPLY <br /> 1 #0 ELLO BE DESTROYED OVER-BORE DIAMETER(sea Weil Deslrucbon Details Table) <br /> WELL ID •MW-3PRESSURE GROUT TO DEPTH of FT BELOW SURFACE <br /> GROUTSPECIFICATIONS Neat Cement per 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,and all applicable California laws. <br /> Signed , !(�i'� Title/Company Senior Geologist Stantec <br /> Print Name Shane Olton Date <br /> �7�} D/" <br /> EPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS �f /�!r/ t�ii.t^/!fi/i �?< ✓��'�1�-�- �� <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED DATEISSUED;�r-' AREA <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 /> O $125 x /, ��7�3 ' SR <br /> RO# <br /> 03 --37---3 0 2 <br /> PR# ' <br /> (2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT e-� ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />