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• • <br /> PA�)a•• SAN JOAQUIN COUNTY ORIGINAL <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> r";.fl■Nt ' K LOP <br /> 600 East Main Street, Stockton, CA 9CvJ029 SITE MITIGATION <br /> Telephone: (209) 468-3147 Fax:(209)468-3433 d11basmUNIT IV <br /> IFO <br /> WELL & BORING PERMIT APPLICATIOWCU <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIQMWU#EMEDIATION <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 wont described..This. p Ion Is made in compliance With San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environhld(A� Grtment. <br /> Site Location 615 E. Main St Cross Street N.American Street City Stockton HH Zip 35202 APN 149-180-07 <br /> Property <br /> owner San Joaquin Cc Real Estate C(Address 343 E. Main St City Stockton Zip 95205 Phone 235-5222 <br /> C-67 Contractor AGE Address 837 Shaw Road Cit, Stockton Lic 680227 Phone 467-1006 <br /> Consultant/Sub Cntr AGE Address 837 Shaw Road City Stockton Lic 680227 Phone 467-1006 <br /> Billable Party AGE Address 837 Shaw Road City Stockton Zip 95215 Phone 467-1006 <br /> GIS Coordinates:X 37.953870 Y -121.278496 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ®NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> N SOIL BORING IDs B4 <br /> ❑WELL IDS <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING . ❑HOLLOW STEM DIA OF BOREHOLE 1 5" ❑MULTIPLE CASINGS Cl MULTI-LEVEL WELL CASING DIA: <br /> —0 EXTRACTION:vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 25' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> 1 f5 SOIL BORING t PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ff No(MAXIMUM FREE FALL DEPTH IS 30 FI) <br /> _❑INJECTION(ie Nr Swme.Om ❑HAND AUGER GROUT SPECIFICATIONS 94 Ib bag oorland cement mixed with 6 gallons of water <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 25' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> Borin will be advanced to 10 feet bs for soil-vapor CCAqSING Df No❑Yes Iasi�s p : Casing De Boring Dia:_ <br /> COMMENTS: 9 9 P ple collet-tion ana then to 2�f€�TT6Y'Soll sample dOtt€CtTOn. <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 [3OVER-BOREDIAMETER 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 <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared his application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable Calif¢rnia latys. __ <br /> Signed �`l// Title/Company Professional Geologist <br /> Print Name Brian Millman r Date 08 October 2014 <br /> DEPARTMENT USE ONLY r <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 0 l J <br /> WORK PLAN DATED I& JOn <br /> APPLICATION ACCEPTED BY G DATE ISSUED /0 AREA <br /> GROUT INSPECTION BY `/,p , ✓{L0M ii�l.0 FINAL INSPECTION BY YL4 Yn[Cir DATE I6 -14- <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: 6 r e-4 Jt <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> REQUEST FIR <br /> 3SaS sl °O ¢130. 0a )(( 410 Co&I jti&� 0 - 9-lq SRa 4o7R7 <br /> 3x03 39orod 390, Oro Roo / 8 <br /> ( R#2 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHO29-01 01/13112 WELL PERMITAPP <br />