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ca`�t SAN .JOAQUIN COUNTY <br /> �.•_fit .o <br /> ENVIRONMENTAL HEALTH DEPARTMENT ,, LOP <br /> y� <br /> •!�-"� 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> .. ;� <br /> Telephone: 209 468-3147 Fax: 209 468-3433 Web:www.siaov.ora/ehd UNIT IV <br /> p ` ' ` ' ORIGINAL. <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 City ROW <br /> Property <br /> Owner City of Stockton Address 425 N.EI Dorado Street City/State Stockton,CA Zip 95202 _Phone_ <br /> C-57 Contractor G/$g prilho.0 Address '05o L 1&10( Afltl 'yCity/State 'r—,4 ,Lie_S/8,S/6�Phone T'Fio 3/3^5&o <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(consuttant> 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: (CHECK ALL THAT APPLY) <br /> 2 #OF WELL(S)TO BE DESTROYED P OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs:BHD-2.PR-2 PRESSURE GROUT (see Well Destruction Details Table) <br /> GROUT SPECIFICATIONS Neat Cement per SJDEH Guidelines ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE X 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 applicable California laws. <br /> Signed Title/Company Senior Geologist { Stantec <br /> Print Name Shane Olton Date _l/'d"-zI <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS / <br /> WORK PLAN DATED A7 <br /> APPLICATION ACCEPTED B / AT _ Wt>1� AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATES-2/—"/ <br /> DESTRUCTION INSPECTION BY DATE Vj <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 /> a $125 x SR# <br /> C' <br /> C. <br /> RO# / <br /> / 3500 C� <br /> PR# <br /> 2900 <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 />