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ORIGINAL <br /> p4Di"� SAN JOAQUIN COUNTY <br /> co[py <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> Telephone:(209)468-3454 Fax: (209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> (/ppR./ <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 Health Department. <br /> Site Location 248 Industrial Cross Street McKenna City Stockton Zip 95206 APN 177-280-20 <br /> Property <br /> Owner Steve Donell, Receiver Address 12.121 Wilshire, #1120 City Los Angeles Zip 90025 Phone 310-207-8481 <br /> C-57Contractor EnProb Address P.O. Box 8093 City Oroville Lie 777007 Phone 530-5B9-2019 <br /> Consultant/SubCntr Pinnacle Env. Address P.O. Box 904 City Clayton Lie Phone 925-673-5500 <br /> Billable Party Steve Donell Address 12121. Wilshire, #1120 City Los Angeles Zip 95206 Phone 310-207-8481 <br /> GIS Coordinates:X 37.90614 Y 121.26967 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> SOIL BORING IDs 8 direct push soil 'borings un to 10 feet to aroundwater with soil and groundwater sampling <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING 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-Aur Soarge,ozor,el❑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: All borings to be abandoned same day as completion. No open boreholes left overnight. <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS []HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS The 8 temporary monitoring -wells are for grab groundwater samoles to be closed same day. <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby cert) that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regyldiions,a all app'ca I a'ornia Laws. <br /> Signed Title/Company Principal/Pinnacle Environmental inc. <br /> Print Name Pete . C1 y <br /> ven DateL 1"5- 1 ao 1 ( <br /> Q DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS _qy �N'!]uSTe�%�L 721 uE <br /> WORK PLAN DATED l<6 -r l 20/Z <br /> APPLICATION ACCEPTED BY j. C>0Kur"l DATE Ar"WA1699 <br /> GROUT INSPECTION BY FINAL INSPECTION BY C W E<5 22/Z <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST P(R'# <br /> 405 S125x / SR# GSSzI <br /> Roo) <br /> PR# <br /> (2900) <br /> C-57 li WC d WAIVER 71= C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC l9 <br />