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• • FILE COPY <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> Q:.: :;..... <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> ., . .:. •;P• Telephone:(209)468-3147 Fax:(209)468-3433 Web:www.siaov.oraleh UNIT IV <br /> lr=s� <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 descdbed. This application is made In compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquln County Environmental Health Department. <br /> Site Location Cross Street tY <br /> 10848 Copperopolis Road South Tulsa Avepuc Ci lstate Stockton,CAZiP 95215 APN 103-11-006 <br /> --T <br /> Property Carl McArthur,Jr. Address 10848 Copperopolis Road City/State Stockton, Zip 95215 Phone(209)910.9635 <br /> Owner <br /> c•57 ContractorCascade Drilling, L.P,Addreas 3000 Duluth Street City/scrteW. Sac C� is 938110 Phone 916.638.1169 <br /> Consultant/Sub CntrThe Source Group Inc.Addiess 944 McCourtney Road,Suite H City/State Grass Valley Uc`T Phone(530)272.4200 <br /> Billable Party The Source Group Inc. Address 944 McCourtney Road,Suite H City/State Grass vatic YZlp Phone (530)272.4200 <br /> GIS Coordinates:X 37 94)!g Y"lzl r)vy 4 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> 0 NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-ANGER,OTHER) <br /> ❑SOIL BORING IDs <br /> 0 WELL IDs AS-LAS-21IS-1 VW- <br /> ❑OTHER to <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _1[g)MONITORING Ul HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASIN 3S❑MULTI-LEVEL WELL CASING OW <br /> 1 ®EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF C NSING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE ETO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM EE FALL DEPTH IS 30 FT) <br /> _LI$I INJECTION&,.mr soeme.more)❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH fl BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: _ Casing Depth: Boring DIS: <br /> COMMENTS:Please see attached Work Plan for construction specifications. <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT To DEPTH OF Fr BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO Fr BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) Fr BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and II applicable California laws. <br /> Signed � Title/Company Project Scientist,Ihe Source Group,Inc. <br /> Print Name Adam Brown ate November 11 2014 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS /'o$YR R046 SL6 <br /> WORK PLAN DATED I1130 1 7`U f 3 I&?5 <br /> APPLICATION ACCEPTED BY .1 s"O DATE <br /> SQ E <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE - <br /> COMM ENTSICONDITIONS; <br /> ACCOUNTING M <br /> FAC# <br /> SERVICE RO# INVOICE <br /> DECODES CHECK# RECV'D BY DATE REQUEST PR# <br /> qo / $ ( v �orrwrs� I(.B. y SR# 70983 <br /> , p y RO# <br /> d. IVJ 3500 <br /> PR# <br /> 2900 <br /> C-57 ✓ WC ✓ WAIVER U fi'- C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT PERMIT APP <br /> EHD 29-01 7/24/14 <br />