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COPY <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> S t•`• <br /> log 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> it SITE MITIGATION UNIT IV <br /> Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.sinov.orgfehd <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 3130 E .Main St.Cross Sbeet S.Golden Gate AvgIly1State Stocktt�'p, 95205 APN 157-104-02 <br /> Props lUIGu.6Z� �� 1r� r B q�� #170-717 <br /> Ow❑ef�869f--Q� �sF] IiU�111LIMILUs2351 Sunset Blvd City/Slate I 95765 Phone916-402-3499 <br /> C-57 contractor Address 9245 Beatty Dr. SCaOSIae 848359 Phone916-363-9355 <br /> RDM ronmenta ins occlli�CA pG 7124 * 916-415-1134 <br /> c�pjItTn�iYn&, Ac dressG280 Brookshire Drct�oc Yin;' �Auc inane <br /> Billable Party Address 6280 Brookshire DrCily/Slate Zip 95677 PhOne916-415-1134 <br /> G**Coorolnates.XX Y <br /> Micnaelton <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING I01 <br /> IN WELL IDs MW <br /> • ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 1 ff MONITORING ffHOLLOW STEM DIA.OF BOREHOLE 8 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASINGTHICKNESS Sch 40 TYPE OF CASING: [3 STEEL [XPVC C OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 45 TREMIE TYPE TO BE USED: C AUGERS D HOSE 0 PIPE <br /> _p SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:If Yes []No(MAXIMUM FREE FALL DEPTH IS 30 FT) SJCEHD specs <br /> • _❑INJECTIONIIeAir9oa,ne.OzonelOHAND AUGER GROUT SPECIFICATIONS Neat cement mixed in accordance w/ <br /> _0 OTHER: ❑OTHER: APPROX.BORING DEPTH J BOLTED TRAFFIC BOX OR [I STOVE PIPE <br /> CONDUCTOR CASING IR No❑Yes:Casing Dla: 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 /> #OF WELL(5)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 <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 he done In accordance with San Joaquin County Ordinances,Rules and <br /> • Regulations,andall ppl le orn w . <br /> Signed Title/Company Principal Geologist/RDM Environmental <br /> Print Name iskael AE Berrington Date 9-16-13 <br /> ppDEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 3 ( 5 C. <' l4' &ti STRC-ET <br /> WORK PLAN DATED R 21.1-4a ( Zo t 3 <br /> DATE ISSUED 9-7- 743 <br /> APPLICATION ACCEPTED BY o aKu AREA � <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 SERVICE RO INVOICE <br /> REQUEST PR## <br /> GO/ S125X 1 CD17oe8G CotuVT�P �'�`�(3 SR# <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER NVt C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EMO 29-01 5/09112 WELL PERMIT APP <br />