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SAN JOAQUIN COUNTY • ORIGINAL <br /> aaP�t..gp <br /> EN IRONMENTAL HEALTH DEPARTMENT LOP <br /> e: < SITE MITIGATION <br /> .: t.. 18 8 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> 4 '•;� Telephone: (20 ) 468-3147 Fax:(209) 468-3433 Web:wWw.siaov.oralehd <br /> �rFOR� <br /> WELL & BORING PERMIT APPLICATION CEIVED <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIA WI <br /> NON-RE UNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAY 0 7 2014 <br /> Application is hereby made to San Joaquin Count for a permit to construct and/or install the work described. This application is made in compliance With Sanr�1 <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department�ERa/I TH <br /> 1245 W. Charter Wy S. Fresno St Stockton 95206 <br /> Site Location Cros Street City/State Zip <br /> Property Geo Properties, Inc. 2306 Jackie Ct Oakdale 95361 Phone 09-848-3272 <br /> Owner Add ss City/State z1p72 904 <br /> C-57 Contractor <br /> V&W Drilling Add $,3806 Duck Creek Drcity/state Stockton Lic_Phone 209-369-9600 <br /> Consultant/Sub Cntr GZA, Inc. Addess 1172 KanSaa Ave City/Slate ModeStd-iC 523a _Phone 209-1;22-4119 <br /> Billable Party Geo Pro"ie Add ss 2306 Jackie Ct City/State Oakdaleip95361 Phone209-848-3272 <br /> GIS Coordinates:X 37 . 1 .3046 <br /> CONSTRUCTION WORKED: <br /> NEW WELLBORING(CPT,GEOPROBE,HYDR PUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs _ <br /> EMTHERIDs - fW-11 . <br /> _ <br /> 19 <br /> TYPE&#OF WELLIBORING yINF,}STALLATI N TYPE CONSTRUCTION SPECIFICATIONS <br /> 3—6MONITORING 79fiOLLOW S1 EM DIA.OF BOREHOLE 2" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION:Vapor/Water ❑HAMMERIDI HVEN CASING THICKNESS RCH 8 0 TYPE OF CASING: ❑STEEL 6 PVC ❑ OTHER <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 1 1 f t TREMIE TYPE TO BE USED: 19 AUGERS ❑HOSE ❑PIPE <br /> — <br /> ❑INJECTION f A , Ozone)❑HAND AUG R GROUT SPECIFICATIONS neat cement grout, 4% bentonite <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 2 5 f t 9BOLTED TRAFFIC BOX OR []STOVEPIPE <br /> CONDUCTOR CASING IJ No Yes:Casing Dia: Casing Depth: Boring Dia:_ <br /> COMMENTS: Refer to 12Z12/13CAP approved b 5 `EHD dated 1 31 13 <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS WdREEM ENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORM D: DESTRUCTION METHOD'(CHECK ALL THAT APPLY) <br /> #OF W ELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEP TNBELOW SURFACE <br /> WELL IDs: <br /> E]PRESSURE GROUT TO DEPTH OF <br /> GROUT SPECIFICATIONS E]EXPLOSIVES FROM ro FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑ OSE F1PIPE [IMUSHROOM CAP AT L3 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 app cation and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,a all appitc le California law . PG, Ground Zero Analysis, Inc . <br /> Signed <br /> Title/Company <br /> Ra nold Kablanow II, Ph.D. Date 3lf -- 5 1 <br /> Print Name Y <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE DDRESS 2yS W ' (4Nk 5 �7TJy <br /> WORK PLAN DATED E-ZEry) <br /> APPLICATION ACCEPTED BY k DAT <br /> GROUT INSPECTION BY <br /> FINAL INSPECTION BY e�DATE Sim <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# INVOICE <br /> PE CODES FEE INFO AMT REM) ED CHECK# RECV'D BY DATE REQUEST PR# <br /> $12s X 75 o eou,vTEe 5 /`� SR# g609 <br /> RO# <br /> 3500 <br /> SSS 3 PR# <br /> 2900 <br /> C-57 WC t/ WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT (/ ENCROACHMENWELLL PEROOCM <br /> EHD 29-01 5/09/12 <br />