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• _ • <br /> U . <br /> SAN JOAQUIN COUNTY v '�✓ � <br /> H �< <br /> 072014 ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1.868 Hazelton Avenue, Stockton, CA:95205-6232 SITE MITIGATION <br /> o4c NMENTk*9AI11 t(209)468.3147 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> PERMIT/SERVICES 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 e-1115.3,and the Standards of the San Joaquin County Environmental Health Department. /67 V rb-ety <br /> Site Location 26e1 a. C.laro.n;a s[raa[ Cross Street City/State Stock"' CA Zip 95206 APN lar moa <br /> Prop <br /> erTy <br /> Owne.A.a.B. S1..k[on, LLC 1<02 E. C.Lt.c.ra 5[ncf. 5[a[k[on. G 95306 <br /> Owner Address C(IyBlate—Zip- Phone 90o so' isse <br /> ,Tvllawan[al C.nci'ol Av591. 691-662-8999 <br /> C•57 Contractor A1ldfeas City/State Llc Phone <br /> ConsultantiSub Cntrsannnih. aai[a. 215. Tcn ne. a1vd, S�.n 2.0 m^.n.a. CA u.nss Tate <br /> Address CilylSlale Lic Phgne <br /> Billable Party"'A'e.e. Stockton, LLC Address 2601 a, nl.ea_:,ln S[:a.[ CIIy/Slate e[. 1[w1- CAZIP 955.. Phone so"sol siu <br /> GIS Coordinates:X 17.227192 y 111.27sii4 <br /> JJ — <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> EI NEW WELL/BORING(CPT.GEgPR BE.HYYDROPVptOH.HAND.AUGER,OTHER) <br /> O SOIL BORING IDs tltl ll 111177 1117 ttiS 11 LL <br /> 0 WELL IDs <br /> 0 OTHERIDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _O MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE1_5 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _O EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL 0 PVC 0 OTHER <br /> —0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> L3-(M SOIL BORING 0 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes XNo(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —OINJECT10NO.e.Aksc9me.O7nna10HAND AUGER GROUT SPECIFICATIONS Neat=ntgrout <br /> _0 OTHER: 0 OTHER: APPROX.BORING DEPTH 15 gn 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> COMMENTS: CT __ _ _ <br /> CONDUOR 25ANGII No 0 Yes:CSSIng Ole: Casing DePlh:^ Bodng Drat_ <br /> NOTE: OFFSITE WELLS ✓3<BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:rCHECKALL THATAPPLYI <br /> #OF WELL(3)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: 0 PRESSURE GROUTTO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS 0 EXPLOSIVES FROM 7D FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:0 AUGERS ❑HOSE 0 PIPE 0 MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> - <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 /> Regulatlo a d all applicable Caltforn a laws. <br /> Signed, �1 ! Title/Company Partner Engineering and Science <br /> Prinl Nam ( /nn+{1 <br /> ', R H(-rrM1 Date 4 <br /> DEPARTMENT USE ONLY N<Tb ti <br /> SITE MAP IN UNIT IV FILE-SREADDRESS_ .Clccio S 9 �t R./yfF� STr2�-C-7-, Sia <br /> WORK PLAN DATED /f}PRESS <br /> L .3 r ?U/ N <br /> APPLICATION ACCEPTED BY J•�2I?KL' a9-t DATEISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIO NS: <br /> ACCOUNTING ONLY: AID# FAG# <br /> PE CODES FEE INFO AMTREMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> �f REQUEST PRO <br /> 5125X G SR# OLfZZ- <br /> U 3 RO# <br /> J 35DD <br /> PR# <br /> 2900 <br /> C-57 , WC _WAIVER�-C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC <br /> END 29-01 5/09/12 WELL PE MIT PP <br />