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r * • r p <br /> apt. SAN JOAQUIN COUNTY <br /> � ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> ay <br /> =','Q'8 �• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> • L.Fh.. <br /> Telephone: (209)468-3147 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <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 ccnslrucl and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9.11153,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 12050 N Curry Avenue Cmss Street Armstrong City/Stare Lodi,CA Zip 95240 APN 061-150-14 <br /> Property <br /> Owner Goldstone Land Co.LLC Address 1190D N Furry Road City/State Lodi'CA Zip 95240 Phone (209)368-3113 <br /> C47 Contractor Woodward Drilling Address PO Box 336 City/State Feo Yia'•cA Uc 710079 Phone (707)3744300 <br /> ConsuhandSub Cntr Fall Creeek Erbr Address PO Box 7834 City/Slate g"wc—cA Lic 55505 Phone (831)426-1440 <br /> Billable Party Bear Creek Winery Address 11900 N Furry Road City/state Lodi,CA Zip 95240 Phone (209)368-3113 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> at NEW WELLMORING(CPT,GEOPROBE,HYOROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> 0 WELL IDS M <br /> ❑OTHER IDs <br /> TYPE&gOF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _®MONITORING 09 HOLLOW STEM DIA OFSOREHOLE B InCh O MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 221nch <br /> _0 EXTRACTION;Vaparr Water 0 HAMMER/DRIVEN CASINGTHICKNESS SCh 40 TYPE OF CASING: ❑STEEL M PVC 0 OTHER <br /> _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 95 TREMIE TYPE TO BE USED: KI AUGERS 0 HOSE 0 PIPE <br /> _0 SOIL BORING 0 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPT1413 30 FTI <br /> _O INJECTION(j,h,Saxae C=ol O HAND AUGER GROUT SPECIFICATIONS Neat cement <br /> _O OTHER: ❑OTHER: APPROX.BORING DEPTH 120 feet 0 BOLTED TRAFFIC BOX OR M STOVE PIPE <br /> CONDUCTOR CASING 0 No❑Yes:Casing Dia:.Casing Depth:_ Bonng 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 /> *0FWE.(S)TOBE DESTROYED ❑OVER-SORE DIAMETER OF__INCHE$TO DEPTH OF FT <br /> WELL IDS: MW-4 ®PRESSURE GROUT To DEPTH of 100 feet FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ea Cement ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERSHOSE ❑PIPE ®MUSHROOM CAP AT Q3 FT) 3 eB_FT BELOW SURFACE <br /> --COMMENTS---- <br /> ` <br /> 6 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby certify that 1 have prepared this application and that the work will be done In accordance with San Joaquin County Ordlnarrcas,Rules and <br /> Regulations,and all ap Cal la I <br /> TitlelCompany Civil Engineer <br /> Signed <br /> Print Name Frederick A. kic Date _0Ila <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED i rl MPLyspa+ED.-- <br /> APPLICATION ACCEPTED BY DgTE ISS "76SE7{` <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK 4 RECV'D BY DATE SERVICE I ROt INVOICE <br /> REQUEST PR: <br /> L <br /> ��{a <br /> SRIt <br /> Z d3 1 Ji3 00 <br /> PRN <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 2g-01 5!09/12 WELL PERMIT APP <br />