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oz.4�l"• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> P: �1 <br /> ` SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> qP Telephone:(209) 468-3147 Fax: (209)468-3433 Web:Www.siaov.ores/eh <br /> FORS <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 County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 500 East Louise Avpross Stfeet Harlan Road City Lathrop Zip 95330 APN 198-120-08 <br /> Property R&B Louise 1200 Concor veSuite 200 c;Concord, CA Zip Phone <br /> phone 9256748400 <br /> Owner Address <br /> c-57contractur AGE Address 837 Shaw Road cityStockton,CA uc 680227 Phone 2094671006 <br /> ConsulfanUSub Cntr " " Address " " City " " Lic " 11 Phone <br /> Billable Party Reynolds/Brown Address 1200 Concord Ave city Concord. CA-p 94520 Phone 9256748400 <br /> G15 Coordinates:X Y Suite 200 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> Xn6lL BORING IDs B# to B# (approximately up to 20) <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF 13OREHOLE2 InCh ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _EI SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 30 ft TREMIE TYPE TO BE USED: ❑AUGERS [ HOSE X PIPE <br /> _SOIL BORING X PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes [ No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _I]INJECTION 0 e AlrSoam.,Doone)❑HAND AUGER GROUT SPECIFICATIONS Pgrtland <br /> _0 OTHER: I]OTHER: APPROX.BORING DEPTH 30 ff ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMIENT 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 GROUTTO 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 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 application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all appligab= California aw <br /> Signed ,,1IJJ.�`"'tt 1 Title/Company AGE <br /> Print Name William Little Date 7/22/15 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE <br /> E�ADYRESS 5IZ4' ZO <br /> -y/ V/SB ✓� LG.7f7r.iy <br /> WORK PLAN DATED //"1/�� <br /> APPLICATION ACCEPTED B AA jj. U� H DATE ISSUED 7ZS�/S AREA <br /> A <br /> GROUT INSPECTION BY Vel ^ do FINAL INSPECTION BYri�� l G/ DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# °FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 1195-7 sR# 67L7?3 <br /> 2903 390 ' 7 390 /1 957 fT072-761/ tk —`? <br /> PR# <br /> (2900) <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT EPC ENT DOC <br /> EHD 29-01 01/13/12 _. _ r.-.' ..! F< „_.... _ _ 1 .! _ s , i _ I 1.!WEW,P✓ERNYThN <br />