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ip <br /> SAN JOAQUIN COUNTYENVIRONMENTAL HEALTH DEPARTMENTrV(ED600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> Telephone:(209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.org/ehd � <br /> WELL & BORING PERMIT APPLICATION EN <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIOORONMHEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVSERV ICES <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 Tide,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 375 West Hazelton Cross Street Scott 95207 <br /> Property City Stockton Zip APN 147-030-31 <br /> Owner Eger Properties Address 375 West Hazelton city Stockton Zip 950207 phone 209-943-7777 <br /> C-57 Contractor Woodward Drilling Address 550 River Road City Rio Vista DC 710079 Phone 707-374-4300 <br /> ConsultanVSub Cntr A.G.E. Address 837 Shaw Road <br /> City Stockton LiC 680227 Phone 209-467-1006 <br /> BillableParty A.G.E Address 837 Shaw Road City Stockton ZiP95205 phone 209-467-1006 <br /> GIS Coordinates:X y <br /> CONSTRUCTION WORK TO BE PERFORMED• <br /> ©NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELLIDS DPE-1, DPE-2 <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 122 ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 4" <br /> 0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS 0.237 TYPE OF CASING: 0 STEEL ®PVC 0 OTHER <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL 6' TREMIE TYPE TO BE USED: ❑AUGERS M HOSE 0 PIPE <br /> _0 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes ®No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION(I e.Air Soame Ozwe)El HAND AUGER GROUT SPECIFICATIONS Portland Type II <br /> _0 OTHER: ❑OTHER: APPROX.BORING DEPTH 40 ®BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth:_ Boring Dia: <br /> NOTE: OFFSITE WELLS 8r BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD•(CHECKALL THATAPPLY) <br /> _#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF <br /> ONS FT BELOW SURFACE <br /> TREM <br /> GROUT SPECIFICATI ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> IE TYPE TO BE USED:E]AUGERS E]HOSE IDPIPE ❑MUSHROOM CAP AT(>3 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,end-ell applicabllaws. <br /> Signed 1 \/ Title/Company Staff Geologist/A.G.E. <br /> Print Name Dan el Villanueva Date 11-9-2010 <br /> DEPATMENT USE ONLY ll <br /> SITE MAP IN UNIT IV F LE-SITE ADDRESS oy, 0,se <br /> WORK PLAN DATED 2VID <br /> APPLICATION ACCE ED BY DATE ISSUED p AREA <br /> 917. <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE! Zi 2Q to <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECWD BY DATE SERVICE RO# INVOICE <br /> 15-01 REQUEST PR# <br /> $122x;L— 31,7-7c7 SR#RO III <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 2901 07/28/10 <br /> WELL PERMIT APP <br />