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ORIGINAL. <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> � < <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> • ;..- --a'P.- Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sigov.orcllehd UNIT IV <br /> CjFQµ <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> Eggiman Hydraulic Garage-"MW8" 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 1112 East Harding Way Cross Street North Union City Stockton Zip 95205 APN 151-02-101 <br /> Properly Robert E Iman 2732 Beileza Drive San Diego 92108 <br /> Owner 99 Address City 9 Zip Phone <br /> C-57 Contractor Cascade Drilling Address 3000 Duluth St City West Sacramento Lic 938110 Phone 916-638-1169 <br /> Consultant/Sub Cntr None Address City Lic Phone <br /> Billable Party NA Address City Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROSE,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 /> _❑INJECTION(i.e.Air$DerOe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑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 ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> I #OF WELL(S)TO BE DESTROYED OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: MW8'� PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TOIBE USED:❑ GERS ❑ SE P MUS O P >3 FT) FT BELOW SURFACE <br /> COMMENTS 11 a I D Q <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 1 hereby certifyAt I have pre red this a > that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, d II app cable s. <br /> Signed ✓`� IIf LawTitle/Company General Manager/Cascade Drilling, L.P. <br /> Print Name Paul Snelgrh1e Date 08/30/13 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE 1871= ---- AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY 'e. <br /> DESTRUCTION INSPECTION BY DATE <br /> COM ME NTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# I <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> $125 x / SR# <br /> R°o <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />