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e4 I" SAN JOAQUIN COUNTY <br /> r ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> c� <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> UNIT IV <br /> Telephone:(209) 468-3147 Fax: (209) 468-3433 Web:www.siaov.oraleh <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 Counly Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 425 W Dr'MILK Blvd Crass Street S.Van Buren city/State Stockton.CA ZP 95206 APN 147-076.07 <br /> Property William Halvorson 10040 Davis Rood Slockton.CA 95209 <br /> Owner_ Address GtylState Zip Phone <br /> C•57Contractor NallonclEWP _ Address 1961 Meeker Ave GtylStale Richmond.CA Ic 953646 -Phone SID-236-6282 <br /> CorrsullanVSub Cntr Siontec _ Address 3017 Kilgore Rood.Ste 100 City/Stats Rancho Llc Phone 916-3B4-0766 <br /> Slanlec 3017 Kilgore Rood.Sle 100 R <br /> Cordova CA <br /> Billable Party- Address 0 CitylSUte ROOChO ZIP 95670 Phone_916-384-0766 <br /> GIS Coordinates:X Y Cadova,CA <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> x NEW WELLIBORING(CPT,rPt1PRr1RP HYDROPUNCH,HAND-AUGER,OTHER) <br /> X SOIL BORING lOs_8-28 <br /> U WELL IDS <br /> ❑OTHER to <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE .3.25- 0 MULTIPLE CASINGS D MULT4LEVEL WELL CASING DIA <br /> _O EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS ❑HOSE 0 PIPE <br /> X SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION It e ),Swme axonal X HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: 0 OTHER: APPROX.BORING DEPTH_10' _ ❑BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> Sea attached table CONDUCTOR CASING X No 0 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 /> #OF WELL(S)TO BE DESTROYED 0 OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SJRFACE <br /> TREMIE TYPE TO BE USED;C1 AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(13 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 1 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,angA applicable California laws. <br /> Signed 1r� Tille/Company4011 It Ops SL.' M nr <br /> Print Name C444 14 ---M'TT.vs', Date 5 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITi ONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR: <br /> 5 130 x SR# <br /> RO# <br /> 3500 <br /> PR# <br /> 2800 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 28-01 724114 WELL PERMIT APP <br />