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o D <br /> 1 S4 ,F. o SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> ,� IIIflONMENT HEALTH 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> c� PEflMIFd $(209) 468-3464 Fax: (209) 468-3433 Web:www.siaov.orQ/ehd UNIT IV <br /> '4•ii9...Rti� <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 2132 E.Mariposa Road Cross Street Farmington Road City Stockton Zip 95205 APN 173-06-35 <br /> Property <br /> Owner Moller Investment Group Address 6591 Collins Drive, Suite Ell City Moorpark Zip 93012 Phone <br /> C-57 Contractor Z I Wi Address r--- ••.--- Cit L._ Phone <br /> Consultant/Sub Cntr Environ Strategy Address 1036 West Taft Avenue City Orange Lic 762798 Phone (714)919-6526 <br /> Billable Party Environ Strategy Address 1036 West Taft Avenue City Orange Zip 92865 Phone (714)919-6526 <br /> GIS Coordinates:X 37.9381,94 Y-121.242067 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ® NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ®WELL IDs VEW-2A/B VEW-3A/B AS-1 IW-1 IW-2 MW-21 <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> -LEI MONITORING El HOLLOW STEM DIA.OF BOREHOLE 8"/10" ®MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> 2 IMEXnTTUGT`N:wiP rl Water [IHAMMER/DRIVEN CASING THICKNESS Sch.401Sch.80 TYPE OF CASING: ❑STEEL RI PVC ❑ OTHER <br /> _❑SCJIL VA//TtPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Neat CementTREMIE TYPE TO BE USED: ❑AUGERS D HOSE ®PIPE <br /> ❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:®Yes ❑No(MAXOMUM FREE FALL DEPTH IS 30 FT) <br /> 3 ®INJECTION(i.e Air Sname.Ozone)❑HAND AUGER GROUT SPECIFICATIONS 6 gal H2O, 1 sack cement <br /> ❑OTHER: ❑OTHER: APPROX BORING DEPTH 60 feet ®BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> �p�t CQttDL�TOR SI [a No 0 Yes:Casing Dia: Casing Depth: _ Bonng Dia: <br /> COMMENTS: Iti--� L✓!'XJC �-Q. h�(Il.'(„_lam/� <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(S)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(>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 prepare application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulatio a II applic ble C nia Laws. ` ''t f <br /> Signed ��^^,c�c�- A ,-.nr Title/Company 'k— 11�r �' � �t('brA ` 2wgj Ct <br /> Print Name —�t+< A L.92Sy rte.^ Date 3,11 -17 , J <br /> -� <br /> _ DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE§ITEADDDRESS ZF—t12_ IVIYJOS--kd St'k.'• LDP 5� <br /> WORK PLAN DATED 1 <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA A <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTSICONDITION S: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> ee Q O REQUEST PR# <br /> _61 $125X / 2 /O �l A� M SR#697 5d <br /> -3 D 371r 7 SJ R°gp ) I <br /> PR# <br /> (2900 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />