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_ r ��J Pf <br /> P Ind- SAN .IOAQUIN COUNTY <br /> r� <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> r,.ML I 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> \'�•.s / UNIT IV <br /> Telephone:(209) 468-3147 Fax: (209) 468-3433 Web:www.slgov.org/ehd <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 3200 E.Main St .CrossStreet S.Golden Gate Avpy/S1a(eStOCktCR 95205 APN 157-110-44 <br /> Property.Gfl IY� 1 R, , G. ETT(- #170-7-1-7- <br /> 0 <br /> 170-7P7 <br /> Owuef m�2351 Sunset Blvd Cit0ate I 95769 PhonegT 6-402-7499 <br /> C-57 Contractor J Address 9245 Beatty Dr. SC /Sriae °' Lie 848359 Phone 916-363-9355 <br /> RDM E ronmen�aTTc oc�c1-t —CA pG 7124 * 916-415-1134 <br /> Gn a nVigrntr Address6280 Brookshire Drc /Stas Uc 0hone <br /> xlable o�Tic. OCk 95677 916-415-1134 <br /> Billable Party Address 6280 Brooks ire DYCity/Slate Zip Phone <br /> G*S Coordin les: Y <br /> Mic�iae Ston <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ­NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑ SOIL BORW�IDs <br /> [N WELL IDs <br /> ' ❑OTHER IDs - <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 1 [4 MONITORING ffHOLLOW STEM DIA.OF BOREHOLE B D MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION.Vapor)Water 0 HAMMER/DRIVEN CASING THICKNESS Sch 40 TYPE OF CASING: 0 STEEL [XPVC 0 OTHER <br /> _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 45 TREMIE TYPE TO BE USED. 0 AUGERS 0 HOSE IN PIPE <br /> _D SOIL BORING 0 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:IffYes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) SJCEHD specs <br /> • _D INJECTION(,a Ag Seeree Orme,O HAND AUGER GROUT SPECIFICATIONS Neat cement mixed in accordance w/ <br /> _D OTHER: 0 OTHER: APPROX.BORING DEPTH 65 6 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING[2 No 0 Yes:Casing Dia: Casing Depth:_ Boring Ola:_ <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 WELLS)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 h ve prepared this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulatio and all p ato la laws. <br /> signeI Title/Company Principal Geologist/RDM Environmental <br /> Print Name Mi ly. Berrington Date 9-16-13 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,SITE ADDRESS t C1 l/LI✓�I N S J SID(lkl <br /> WORK PLAN DATED SERau A -f l� 570/Z <br /> ` APPLICATION ACCEPTED 8Y w DATE ISSUED AREA c19 <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 REQUESSERVICET RO# <br /> PR# INVOICE <br /> �CtU/ $1225X I G1' ury q 'Zy-/S SR# c�U)Sl <br /> �Q(7�J J7S (3o0) 4P <br /> PR# <br /> (2900) <br /> C-57=WC __WAIVER ,TJ V1- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ /,ENCROACHMENT DOC L1 <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />