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• <br /> C � LIV <br /> r5 * <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> � Telephone: (209) 468.3147 Fax: (209) 468-3433 Web:www.si-lov.or4/ehd <br /> tIFO <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> ^NQN-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 Street S.Golden Gate AvintylstateStocktc�'pi 95205 APN 157-104-03 <br /> Proper�t4y TF1 /0- 11 1 <br /> M014 HuntbY00k HoldingsgATgjy�'s 2351 Sunset Blvd CitV4 ate p 95765 Phone9T6-402-3x99 <br /> CC-57 Contractor, Addiress954 N Lemon St pile/Sl eaockt:'Lic 899451 Phone714-633-5025 <br /> CnRDM E ronme Inc 6280 Brookshire DrCI't/st a Lic PG 7124�13`bne 916-415-1134 <br /> • x5gllap ulro`nmenta�;�TTcAddress oc�c�A <br /> Billable Party x Address6280 Brookshire Drcity/state zip95677 Phone916-415-1134 <br /> *i*c M dcVae�. errington <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,CEPOTROiE,HYDROPUNCH.HAND-AUGER,OTHER) <br /> IN SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2-.in D MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _D EXTRACTION-Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 10 D TREMIE TYPE TO BE USED: ❑AUGERS D HOSE ff PIPE <br /> 1[SOIL BORING LXPUSH POINT(GPI CPT)'1 GROUT SEAL PUMPED:ff Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) SJCEHD Specs <br /> • _D INJECTION t'a A5 ozer,i0 HAND AUGER GROUT SPECIFICATIONSN ament mixed in accordance w/ <br /> ft <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No D Yes:Casing Die: Casing Depth:_ Boring Die:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLYI <br /> • _#OF WELLS)TO SE DESTROYED ❑OVER-BORE DIAMETER OF_INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONSElEXPLOSIVES FROM 70 FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 6 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have pro ed this application and that the work will be done In accordance with San Joaquin County Ordinances, Rules and <br /> • Signe tl and�1 0d04bW 411t n a ws. <br /> signed �c }K5�/WJJ Title/Company Pr ncipal Geolocxist/RDM Environmental <br /> PrinLName Michael Berrington Date 10-23-13 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS Y/130 C. migis) f I <br /> WORK PLAN DATED 45A*Wt( 1/0 Zell <br /> APPLICATION ACCEPTED BY J. `I p*444 e2 GATE ISSUED 10-3 '�� AREA /(s <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICON DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# INVOICE <br /> P1EnnCODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# <br /> �O1v'rF�S S125X 06 Zq2C. 0.,Ct1 /04-13 SR# 7-CO <br /> ng03 7 S 3500 <br /> PR# <br /> 29°0 <br /> • C-57. y/ WC WAIVER,�� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ,T_[�. ENCROACHMENDOC E iiAIT P <br /> EHD 29-01 5/09/12 ni <br />