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oe441y- • SAN .JOAQUIN COUNTY is <br /> >••�+`'•p LOP <br /> D <br /> ENVIRONMENTAL HEALTH DEPARTMENT a; a SITE MITIGATION <br /> u: < <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> d•., Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> tli'•oi4�. <br /> WELL & BORING PERMIT APPLICATION <br /> �E COPY <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMALE <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 508 W Charter Way Cross Street S Lincoln St City Stockton Zip 95206 APN 16504016 <br /> PropertyLYNETrs-� EWGELHAitOTETAL 14936HA1E01lCTa t�Tt Rop 75330 Yrt /o-It X11 <br /> Owner -k;ne„ron Address-6103-BGginger GaRyon-Road- City-'& R­Raffl=— ZV� Phone-(9a <br /> C-57 Contractor WDC Exploration&Wells Address 9580 Country Road 938 City Zamora Lic 283326 Phone (530)668-7540 <br /> Consultant/Sub Cntr Stantec Address 3017 Kilgore Rd, Suite 100 City Rancho Cordova Lic 654498 Phone (916)861-0400 <br /> Billable Party NA Address City Zip_�"i�ipra _ <br /> GIS Coordinates:X Y �-1�#4�.+4•^°' M ;T gam., <br /> CONSTRUCTION WORK TO BE PERFORMED: , OC T ZO)) �dk <br /> NEW HULL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ©WELL IDs VE-1 AS-1 AS-2 PZ-1 PZ-2 , a„�CfH <br /> ❑OTHER IDs - <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS cR.'V111;'S_i=;`fl�rL� <br /> _❑MONITORING EI HOLLOW STEM DIA.OF BOREHOLE 10 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> -LIM EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS 2”&4"dia. TYPE OF CASING. ❑STEEL XI PVC ❑ OTHER <br /> _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Varies TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE X1 PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> 20 INJECTION r e A,,Soaroe.O=nel❑HAND AUGER GROUT SPECIFICATIONS Portlandcement <br /> Z®OTHER: PIEZOMETER ❑OTHER: APPROX.BORING DEPTH down to 38 ft bgs 91 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING®No❑Yes:Casing Dia: Casing Depth: Boning Dia: <br /> COMMENTS: AS=2"dia,VE& PZ=4"dia., <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: NA DESTRUCTION METHOD:lCHECKALL THAT APPLY) <br /> _#OF WELL(S)TO BE DESTROYED ElOVER-BOREDIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: El PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE p „ <br /> COMMENTS �J <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS C <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,andapplicable California laws. <br /> Signed fit.-/.L_J 1 Title/Company Senior Geologist/Stantec Consulting Corporation <br /> Print Name Brian Westhoff Date AZA (( <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS JOB W nhar-IGr Way <br /> WORK PLAN DATED 0h _ <br /> APPLICATION ACCEPTED B,Y/ - DATE ISSUED /6 - 7/-/l AREA�-TR <br /> GROUT INSPECTION BY Y I Cht-i Q IYI�r•IYr�(.r FINAL INSPECTION BY \f,.4&r`.i)T Idnnc DATE 11-4-/ <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: I i AS- E- Z' h <br /> ACCOUNTING ONLY: AID# FAC# -� <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> C <br /> 9 $12 x 5 G25• 00 (U -2/ 41 SR# 3950 <br /> 2903 X395• o0 3 '%5. 0U 3500 <br /> PR# <br /> 1 0 0 0 . 00 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 WELL PERMIT APP <br />