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SAN .IOAQUIN COUNTY Copy <br /> r. ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> Q: <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION ' <br /> me q' Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.sIgov.oralehd UNIT IV <br /> LIFOR� <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES i 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 Street S.Golden Gate A-vigity/Slate Stocktc9iIa 95205 APN 157-104-03 <br /> PropsnrtvvunKbroo Hol in 2351 Sunset Blvd RI /U- /-Lt — <br /> Ca�Y�' H � T d g'so i' s� on Me 1gl o1e r p 95765 Phone916-402-1489 <br /> C.57Contractor, Tnr ddress - it;e—� CI't,v;Ia Bp is 884827 Phone650-854-0300 <br /> p�Rp5DpM F� B�JC�ronmen�J.ncAddress62$0 Brookshire DrOK/SCaeliT CALiCPG 71241#hone 916-415-1134 <br /> Rbq InvTrorm[en-ta� YrrcAddress 62$0 Brookshire DrClty/sla�e 1177' C"Ztp95677 Phone916-415-1134 <br /> Billable Party <br /> Gil*Coorlilntes:X Y <br /> Mic�Tael err.ington <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER) <br /> MSOILBORINGIDS CPT-1 <br /> ❑WELL IDs <br /> • ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM OW OF BOREHOLE 3-in 43 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑r SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [I AUGERS ❑HOSE 12 PIPE <br /> 1��SOIL BORING 6 PUSH POINT(GPI CPT) GROUT SEAL PUMPEDffYes O No(MAXIMUM FREE FALL DEPTH IS 30 FT) SJCEHD specs <br /> • _❑INJECTION(,Ar Soar,e.Onnei 0 HAND AUGER _GROUT SPECIFICATIONS Neat cement mixed in accordance W/ <br /> _❑OTHER' ❑OTHER: _APPROX.BORING DEPTH 100 , ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No 0 Yes:Casing Ole: 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•ICHECKALLTHAT APPLY) <br /> _#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER of_INCHES To DEPTH OF FT <br /> 0 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(>3 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 applicatlon and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> • Regulations a and all a Ica Ca Is s. <br /> Signed ��, TilleJcompany Principal Geologist/RDM Environmental <br /> Print Name nichae . Berrington Date 9-25-13 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 1 38 C 041¢(N 5T �Tcx'+K PrN/ <br /> WORKPLANDATIED ;EC� R(ARr�Rj (/t20 / -3 <br /> 0 APPLICATION ACCEPTED BY , -1 a /frG.t ✓I DATE ISSUED IV-345 AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICO N DITI ON S: <br /> ACCOUNTING ONLY: AID# FAC# - SERVICE RO# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST <br /> ppPR# INVOICE <br /> , "�C) $125x 1 Q7 Q 2,4(Z G C� e.-C-E10'1-1 3 SR# �PU 100 <br /> uPL3�S RO# <br /> QU 3 <br /> 3500 <br /> PR# <br /> 2900 <br /> 729 0 5/09/12 WO / WAIVER� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT d ENCROACHMENT DOLOE� <br /> 0 EH0 <br />