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COPY <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> • �ISI I 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone:(209) 468-3147 Fax:(209) 468-3433 Web: ww.slgov.orglehd UNIT IV <br /> w <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 3138 E .Main St .Cross Slreet S.Golden Gate AV*Iy/Shde StocktC4 95205 APN 157-104-03 <br /> Propert 170-71 /— <br /> Owu tiuntbrook Holdings Ardkogss2351 Sunset Blvd it late i 9S7CS Phone916-4n7-3499 <br /> 9245 Beatty Dr. Sacrgm <br /> C-577 Contractor, Address Y C' /Sit is 848359 Phone916-363-9355 <br /> RDM ETtp1ronmen a , .Lnu oc 1 -CA <br /> It US1'Wtr Address 6280 Brookshire Drc- /Slae UDPG 712404ne 916-415-1134 <br /> Benviro�°nddress6280 Brookshire DOCkA 95677 916-415-1134 <br /> Party rCitylSlale Zip Phone <br /> GI*Coordin lead xx Y <br /> Miclaiael ton <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING ID� <br /> IN WELL IDs MW <br /> • ❑OTHER IDs <br /> TYPE 8#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 1 IN MONITORING ff HOLLOW STEM DIA.OF BOREHOLE B-i 13MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA. <br /> _O EXTRACTION.Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS S ch 40 TYPE OF CASING ❑STEEL ffPVC ❑ OTHER <br /> _p SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT BEAL45 TREMIE TYPE TO BE USED ElAUGERS [IHOSE ff PIPE <br /> _0 SOIL BORING [I ,,ss��PUSH POINT(GPI CPT)-1 GROUT SEAL PUMPED L1Yes ❑No(MAXIMUM FREE FALL DEPTH IS 31 FT) SJCEHD Spec S <br /> • —0 INJECTION ue PV Soaae Oeonu❑HAND AUGER GROUT SPECIFICATIONS Neat cement mixed In accordance w/ <br /> _I]OTHER. ❑OTHER APPROX BORING DEPTH 6 5 I 6 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING IN 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 ALLTHAT 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 FTBELOW 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 this application and that the work will be done In accordance with San Joaquin County Ordinances, Rules and <br /> Regulations nd I allf 'at wS. <br /> Signed <br /> Tiile/Company Principal Geologist/RDM Environmental <br /> Pfint Name i hael , Berrington Date 9-16-13 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SIT ADDRESS 3/ 3F2 E- • lM nrN s7—R.ec-7 S 130,K Ty&J <br /> WORK PLAN DATED NE INP.UARh I ( � 7U/3 <br /> •, APPLICATION ACCEPTED BY -f , N O Yj Cu DATE ISSUED AREA /G 4 9 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <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 SERREQUVICE R°EST PR## INVOICE <br /> • <br /> m <br /> 290 / 5125: CU 17�� G Cfi2uF�1tFL -Z`//3 SR# <br /> RO# <br /> 199) 3 3 7 3500 <br /> PR if <br /> 2900 <br /> C-57 ✓ WCy WAIVER__yt/_{a. C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _1_- ENCROACHMENT DOCS <br /> • EHD 29.01 5)09112 WELL PERMIT APP <br />