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0 i . . ; <br /> z oly SAN JOAQUIN COUNTY <br /> Tug` ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> ✓H' <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> UNIT IV <br /> Telephone:(209) 468-3147 Fax:(209)468-3433 Web:www.sinov.orn/eh <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 374 Lincoln Center Cross Street 'Nest Benjamin Holt City/State. Stockton,CA Zip 85207 APNQ9741029 <br /> Property <br /> Owner cn�nraWWLTOwSh .p.uom.c Address 374 Lincoln Center Clty/State Stockton,CA Zip 95207 Phone 209-478-9200 <br /> C-57 Contractor National E.W.P Address 1861 Meeker Ave City/State Rlcnmond,CA Lic 953646 Phone 510-236.6282 <br /> Consultant/Sub Cntr Address City/State Lic _T Phone <br /> Billable Party Geosyntec Consultants Address 3042 Gold Canal Drive Suite 201 City/State Zip 95670 Phone 916-637-8048 <br /> GIS Coordinates:X 121.321172°W y 38.008905°N <br /> a�Fz o0�1�2/s <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER( <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHERIDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING Q HOLLOW STEM DIA.OF BOREHOLE_,T 0 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _O EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _11 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes Q No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —0 INJECTION ri.e Air soeme Ozones❑HAND AUGER GROUT SPECIFICATIONS <br /> _EI OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING❑No Q Yes:Casing Dia: Casing Depth:. Boring Dia:_ <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> ^?#OFWELL(S)TOBE DESTROYED QOVER•BORE DIAMETEROF s.a Tsw- INCHES TO DEPTH OF Bee Table <br /> WELL IDs: aee T.wte ❑PRESSURE GROUT TO DEPTH OF FTBELOW SURFACE <br /> GROUT SPECIFICATIONS NOMCc cun(941bbagl&Sgallonswator ❑EXPLOSIVES FROM TO Fi BELOW SURFACE <br /> TREMIE TYPE TO BE USED:X AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP A7 L>3_FT)___ FT BELOW SURFACE <br /> COMMENTS Tables,figures,access agreement attached <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,arld all applicable California laws. / <br /> Signed Lam?. Title/Company Project Geologist /Nto�ynfcr <br /> Print Name Timothy Davis Date 8/22/2014 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITEADDRESrS_ ew(fie d" EN (^/ozr a S 7zerrofv <br /> WORK PLAN DATED 1. 1 )A1 Ll <br /> p Q <br /> APPLICATION ACCEPTED BY J . a(.gaCu DATE ISSUED S• Zs 1 CI AREA G / <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 SERVICE RO# INVOICE <br /> REQUEST PR# <br /> ago <br /> S 130 X04 ICY040 2233-TZ &L'VfZ°Q 8'Z2-fy SR# eb 383 5' 01 <br /> 2803 3 O 390 t Ro# <br /> 350D <br /> PR# <br /> 29D0 <br /> C-57 !i WC WAIVER_ V C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ - ENCROACHMENT DOC, _ <br /> EHD 29-01 7/24/14 WELL PERMIT APP <br />