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•• R -=LVED Ulf <br /> SAN JOAQUIN COUNTY JUL 3 0 201 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Q:.��.,..•$.i., •�� LOP <br /> 1868 Hazelton Avenue, Stockton, CA 0M8Q9N=7NTALHEAff[-PITE MITIGATION <br /> �' �:•;;:P. Telephone:(209)468-3147 Fax.(209)468-3433 Web-�!P-C�(�gghpd UNIT IV <br /> Tito <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 He�ltt�Department <br /> HFI! <br /> Site Location 7675W.11th Street Cross Street Poplar City/State Tracy,CA Zip 0 t/ APN 250-140-12 <br /> Property Yvonne Miller <br /> Owner Address P.O.Box 366 City/State Tracey,CA Zip 95378 Phone 209-635-3466 <br /> C-57 Contractor Greg Drilling Address 950 Howe Ave. City/State Marilnez,CA Lie 4$5165 Phone CtA5-313-5800 <br /> Consultant/Sub Cntr CardnD Address 1117 Lone Palm Ave.,Suite 2018 City/State Modesto,CA Lie 95351 Phone 209.579.2221 <br /> Billable Party Cardno for Yvonne Miller Address 1117 Lone Palm Ave.,Suite 2018 CitylState Modesto,CA Zip 25351 Phone 209.579.2221 <br /> GiS Coordinates:X 37.740 Y-121.400 <br /> -97• 7' —r zl ygci3 V <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑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 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION fl.e.AtrSoerae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: 0 OTHER: APPROX BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dla: <br /> COMMENTS:_Cement skirt s firrotrnding well bnx Will hP'PDlarPrI <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD CHECK ALL THATAPPL <br /> w #OF WELL S) O BE DES T OYED ❑OVER-BORE DIAMETER OF - INCHES TO DEPTH OF 20-27 FT <br /> WELL IDs; M0 1T-9. AS-�. AS-2. QP 1-3 ❑PRESSURE GROUT TO DEPTH OF FTBELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE 0 PIPE ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> 1 hereby certify that 1 have prepared this applicatio and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all ap cable C ifor a la <br /> Signed Title/Company Staff/Cardno <br /> Print Name Charlie Selkow Date 7-,2k^I Li <br /> DEPARTMENT USE ONLY <br /> SITE MAP INUNITIVFILE-SITEADDRESS_ 705- W, It <br /> WORK PLAN DATED J L,1, / 20 114 <br /> APPLICATION ACCEPTED BY DATE UE - Cf-/<I A l �/ <br /> GROUT INSPECTION BY FINAL INS EC ION B� ATE <br /> DESTRUCTION INSPECTION BY DATES <br /> COMMENTS/CONDITIONS: a-t r <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> �7 u REQUEST PR* <br /> 121 C, �- ]y SR# 20 zU <br /> lJ ir' '1 <br /> 3�3 3y� RO# <br /> 3500 0Q Z <br /> PR# <br /> 2900 <br /> C-57_� WC WAIVER_ Iy fQ- C-57 LETTER OF AUTHORIZATION TO SiGN PERMIT _ [i ENCROACHMENT DOC <br /> EHD 29-01 S/O�JH2 WELL PERMIT APP <br />