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°�"'�'• SAN JOAQUIN COUNTY �
<br /> ` ENVIRONMENTAL HEALTH DEPARTMENT LOP
<br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATIORI,
<br /> �;•: - ::a: Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.si-gov.org/eho IV
<br /> L1FOR
<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/nF;compliance=wi(l'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 097-630-32
<br /> Property Buena Park,
<br /> Owner BP West Coast Products Llc. Address P.O.Box 5015 City/State CA Zip 90622 Phone
<br /> C-57 Contractor reiq Dr;Ijl h ' "
<br /> Address ql j9 ff?Wt 444 City/State�y' � Z _ic ug5lVS Phone,r!9Z5)313�$DD
<br /> ConsultantJSub Cntr Stantec Consulting Address 3017 Kilgore Road,Suite 100 City/State Rancho Lic 95670 Phone 916-861-0400
<br /> Billable Party(cons.nancServices,Inc. Address City/State Cordova,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 /> ❑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,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: ESTRUCTION METHOD: CHECK ALL THAT APPLY
<br /> 31 #OF WELLS)TO BE DESTROYEDE-2,E-3,E-4,E-5,E-6,E-9,E-10,E-11,E-12,MW-1,MW- - OVER-BORE DIAMETER(see Well Destruction Details Table)
<br /> WELL IDS:V-1,V-2,V-3,V-4,V-5,V-6,V-7,V-8,V-9/S-7,V10/S-8,V-11,V-12,S-1,S-2,S-3,S-4,S-5,S-6,S-9 X 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:AUGERS ElHOSF PIPE MUSHRQOM CAP AT(>3 FT) 3 SFT BELOVY SURFACE
<br /> COMMENTS V-(otV-8,S��. S-�/�¢-Z �'�i� -S,E•9,EII�E-I�rNW-i �lw-2® r�� VI0�5•� aye p►Y�urQq,�oy --
<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 _�tI Title/Company Senior Geologist Stantec
<br /> Print Name Shane Olton Date 7
<br /> DEPARTMENT USE ONLY
<br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS
<br /> WORK PLAN DATED 4 F
<br /> APPLICATION ACCEPTED Y - ATE I ' t REIT
<br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE
<br /> DESTRUCTION INSPECTION BY DATE
<br /> COMMENTS/CONDITIONS:
<br /> [PE
<br /> COUNTING ONLY: AID# FAC#
<br /> CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE
<br /> / REQUEST PR#
<br /> -5 $125 x,:�V SR#�)
<br /> RO#
<br /> 7�Q0 3500 �o
<br /> PR#
<br /> -j y 7 -P (2900
<br /> C-57 WC WAIV C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC
<br /> FHn 99-01 F/nq/1g WFI I PFRMIT APP
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