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p4 '" 0 SAN JOAQUIN COUNTY * F 11' r copy <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> - 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> ).F. <br /> Telephone: (209) 468-3454 Fax: (209)468-3433 Web: www.siaov.org UNIT IV/ehd <br /> CIFOR <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 Count Develo ment Ttle,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location700 South EI Dorado Cross Street East 3rd Street city Stockton zip 95206 APN 167-033-26 <br /> Property Sora Jimin Housing Investment 1209 East 8th Street Stockton 95206 209-937-7625 <br /> Owner G P Address City Zip Phone <br /> C-57 ContractorAdvanced GeoEnvironmentaAddress 837 Shaw Road Cit, Stockton Lic 680227 Phone209-467-1006 <br /> ConsultanVSub(APanced GeoEnvironmenAdress 837 Shaw Road City Stockton Lic 680227 Phone 209467-1006 <br /> Billable Party Advanced <br /> -7GeoEnvironnpm�'ental Address 837 Shaw Road City Stockton Zip 680227 Phone 209-467-1006 <br /> GIS Coordinates:X3?. t{C57Y _/ZI• )3 t <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ®NEW® OIL BOR NG IDs SE PSV2,,SV3R PU CH,HAND-AUGER,OTHER) <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA OF BOREHOLE 125 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Up t0 10' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes LN No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(ia AT$nave,Owne L)HAND AUGER GROUT SPECIFICATIONS Type 1/11, neat cement <br /> OTHER: ❑OTHER: APPROX.BORING DEPTH UP to 10' ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE <br /> CONDUCTOR CASING❑No❑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 WELLS)TO BE DESTROYED ❑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 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 t <br /> Regulations,an Ira Ip ir�b ornia lam President,Advanced GeoEnvironmental <br /> Signed � Title/Company <br /> Et Print Nae <br /> f�obert May Date 02/24/2015 <br /> Nan <br /> `y DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY1,461.83MM!EWA <br /> GROUT INSPECTION BY FINAL INSPECTION BYY <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES E INFO MT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> $fievx ( 1/z6 �otti.v 3-4-IS SR# 7/ <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 / WC ✓ WAIVER_,AZ�C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC A/Yd <br /> WELL PERMIT APP <br /> EHD 29-01 07/28/10 <br />