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FILE COPY <br /> OPgUIry' Q SAN JOAQUIN COUNTY <br /> 2 �ti <br /> 2 ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> a: -t <br /> t '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 d MITIGATION <br /> \�`;•.;;'::: .�;;P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/eh <br /> ��FOR <br /> WELL & BORING PERMIT APPLICATION 15 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIONPR ZC <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EMVfRGiVMECrhE <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is madeltl t43ffiJl�[e �t1 <br /> Joaquin County Developmen Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. J <br /> 0/67 P rEr< 'Iwc <br /> Site Location 6025-6049 Pacific Avenue Cross Street Swain Road City/State Stockton Zip 95207 APN 097-464-06 <br /> Property <br /> Owner Miller Tnst Address 3031 West March Lane City/Statestockton Zip 95219 Phone 209-474-7872 <br /> Advanced GeOE.,ironmentalnc B37 Shaw Road Stockton 680227 209-467-1006 <br /> C-57 Contractor kddress City/State Lic Phone <br /> Consultant/Sub Cntr Advanced Geo Environ-Abb igS 837 Shaw Road City/State Stockton Lic 680227 Phone 209-467-1006 <br /> Billable Party AGE Address 837 Shaw Road City/State Stockton Zip 95215 Phone 209-467-1006 <br /> GIS Coordinates:X 038.00 5255 Y —1 zl .3 1 TOi S <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> I]SOIL BORING IDs B1, B2, v1 and v2 <br /> ❑WELL IDs <br /> ❑OTHERIDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0.25" and 1.25" <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> 2 ©SOIL VAPOR PROBE10 and 15❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> 2 ®SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑ <br /> INJECTION(i.e.AirSparge,Ozone l❑HAND AUGER GROUT SPECIFICATIONS Portland cement (6 gallons per 94 lbs bag) <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH to and 15 feet bag ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: 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 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(>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 application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations dnclall appl/ic a California laws. <br /> Signed �/ p y Project Geologist <br /> Title/Com an <br /> 04-14-2015 <br /> Print Name Daniel Villanueva Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS (01477 Pel Pld <br /> WORK PLAN DATED G, 2.A f • <br /> APPLICATION ACCEPTED BY DATE I EA <br /> GROUT INSPECTION BY FINAL INSPECTION BY TE <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 /> ?C REQUEST PR# <br /> 0 1) $130x J I CS !l�l S� �'actiTEQ y`l5 'r� SR#Gb 7 <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 I/ WC iLWAIVER ( C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT p-ENCROACHMENT DOCS <br /> EHD 29-01 7/24/14 WELL PERMIT APP <br />