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o •�" " <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION t i 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> • UNIT IV <br /> c,.::,�„:.::�• Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siclov.orcglehd <br /> �/FORS <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 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 1 ,�f L City/State Stockton,CA Zip 95207/ Phone <br /> C-57 Contractor 6r gp"lliejJ Address9'J0#p,W,e d�AJarfi�iCity/State 44- Lic? W/(o S_Phone��LS�3/3 -58oD <br /> Consultant/Sub Cntr tantec Consulting Address 3017 Kilgore Road,Suite 100 City/State Rancho Lic 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.Air Sparge.Ozonel❑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: CHECKALLTHAT APPLY) <br /> 1 #OF ELL( ) BE DESTROYED <br /> WELL ID-MM`�`�-3 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Neat Cement per SJDEH Guidelines ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERRR ❑HOSE X PIPE p 5�MUSHRO,QM CAP AT L>3 FT FT BELOW SURFACE <br /> COMMENTS Aw^ ~0V 0 C 4,,ellfl�f <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,andallapplicable California laws. <br /> Signed `ITitle/Company Senior Geologist Stantec <br /> Print Name Shane Olton Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS �9 n X7 <br /> WORK PLAN DATED 141 Of <br /> SS r <br /> APPLICATION ACCEPTED S 2 AREA <br /> GROUT <br /> �,,Q <br /> GROUT INSPECTION BY FINAL INSPECTION BY J/ u� DATE �3 _' <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 /> $125, ✓, O / SR <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _- ' ENCROACHMENT DOC <br /> FHn 9a_m rInwig I <br /> WELL PERMIT APP <br />