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a�IN ;; FILE COPY <br /> SAN JOAQUIN COUNTvRF .,F -, <br /> ENVIRONMENTAL HEALTH DEPARTW-_NrT2, 2, (1014 <br /> LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> "Cr.n�fj-� UNIT IV <br /> Q j�b'fF't* Telephone: (209) 468-3147 Fax: (209) 468-3433 Wca*�4,0'jk 9V !6r <br /> WELL & BORING PERMIT APPLICHO' <br /> 62 � <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 Health Department- <br /> Sl'te Location 108.2 S liarian Rd Cross Street Roth Road <br /> Property Ci /State French Camp�ZiP_2S23j_ APN 19-3-3.30-28 <br /> CA <br /> Owner. Bencto,Inc. Address 4080 Seaport Boulevard City/State W.Sacramento,Zip 9.)691 Phone 916-677-0917 <br /> C-57 Contractor Woodward Drillini, Address PO Box 336 City/State R o Vista,CA Lie C57-710079 Phone 707-374-413()() <br /> Consultant/Sub Cntr—Caledonia AssociateS Address -1,100 Market Strct-r City/State Redding.CA Lie—Phone 53n_5,)4_69()6 <br /> BillableParty PapoProperties,inc. 2L212L <br /> Address PO Box.107 Cit !State Eugene,01t ZiP-2L/4_40 Phone 541-341-3344 <br /> GIS Coorclinat,,.X .377.858194 Y 121.278972 <br /> T-?.F2 Sb 34 —17-(, <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> E]NEW WELL/BORING(CPT,GEOPROB­E,HYDROPUNCH,HAND-AUGER,OTHER) <br /> SOIL BORING Ds SB-1 SB-2,SB-3,SB-4 <br /> ❑WELL IDS <br /> CIOTHER IDs <br /> TYPE&#OF W KLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _E]MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 3" 0 MULTIPLE CASINGS n MULTI-LEVEL WELL CASWC DIA: <br /> _[J-EXTRACTION:Vapor/Water <br /> El HAMMER/DRIVEN CASING THICKNESS A114 TYPE OF CASING- 0 STEEL [j PVC 0 OTHER #(4 <br /> —0 SOIL VAPOR PROBE E]MUD ROTARY DEPTH OF GROUT SEAL 2S 1 TREMIE TYPE TO BE USED: [I AUGERS D HOSE 0 PIPE <br /> _M SOIL BORING IQ PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes 12 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —0 INJECTION(i P. Air Sparge 07ono.1❑HAND AUGER GROUT SPECIFICATIONS Nevr� CFaMtlnt 9V-D0+ <br /> —0 OTHER: ❑OTHER: APPROX.BORING DEPTH 21;1 —C BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING qNo 0 , <br /> Yes:Casing Dia. VIII. CasingDepth:_ AlItt goring Dia: AJIA <br /> COMMENTS: fe-6, q- 1..rJA%1; 4L n faile'i- it f7 LJr4ee <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY <br /> _ALA_#OF WELL(S)TO BE DESTROYED ❑ <br /> _I <br /> WELL IDS: Lj OVER-BORE DIAMETER OF Afj4 INCHES TO DEPTH OF--61* FT <br /> GROUT SPECIFICATIONS 4 <br /> 0 PRESSURE GROUT TO DEPTH OF A11A FT BELOW SURFACE <br /> #vt :- [I EXPLOSIVES FROM NA TO NIA FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:Lj AUGERS [D HOSE LJ PIPE []IMUSHROOM CAP AT L>3 FT). A114 <br /> COMMENTS A(14 FT BELOW SURFACE <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 /> Regulation ,and all_applicable California laws. <br /> Signed Title/Company:P azu('A'0 ti nod '4 I(..[A r_ <br /> Print Nam, r1rAE. 41-2=1 LocA.izud Dat 1j <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 103y?- S. 17191l?4j-9,V d2Q__An;o fRc-g�ew <br /> WORK PLAN DATED Pf ?-Of q <br /> APPLICATION ACCEPTED BY j. DAT <br /> A, co _AREA_1ff.9q <br /> GROUT INSPECTION BY <br /> DESTRUCTION INSPECTION BY FINAL INSPECTION BY -DATE-jo-�t;' <br /> DATE <br /> COMM ENTSICONDITIONS; <br /> ACCOUNTING ONLY: - - AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVI�Ro�# INVOICE <br /> DATE REQUEST I PIR# <br /> _/"t <br /> '11 o5 S 1?6)x Zo 4-178 32 SR# 7042 <br /> 2-qc) 3 DO RO# <br /> (3500) <br /> PR# <br /> C-57 V (2900) <br /> EHD 29-01 5/09112 WC L�V�VAP-Oft- C <br /> WAIVER -57 LETTER OF AUTHORIZATION TO SIGN' L,-'ENCROACHMENT ENCROACHMENT DOC 4119 <br /> WELL PERMIT APP <br />