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SAN JOAQUIN COUNTY <br /> ., "' ENVIRONMENTAL HEALTH DEPARTMENT <br /> EPARTMENT huj LOP <br /> / 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone:(209) 468-3147 Fax:(209)468-3433 Web:www.siaov.ora/eh UNIT IV <br /> .4,ti F oyi±v <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 6455 Pacific Ave Cross Street West Benjamin Holt Stockton,CA 95207 9741029 <br /> Property City/Stale Zip APIJd <br /> Owner remaam —uc�Leae.a., aaeaa,,a.,,,., Address 2500 Ventura Oaks Way City/State sa`m'"T_nio.c" ZIp95333 Phone 916-646-8211 <br /> C-57 Contractor National E.W-P Address 1961 Meeker Ave City/State Ricbmond_CA Lic 953646 Phone 510-236-6282 <br /> Consultant/Sub Cntr Address City/State Lic _Phone <br /> Billable Party Geosyntec Consultants Address 3042 Gold Canal Drive Suite 201 City/State Zip 85670 phone 916-637-8048 <br /> GIS Coordinates:X 121.321172°W Y 38.008905`N <br /> ,L7 �y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> []SOIL BORING IDS <br /> ❑WELL IDs <br /> ❑OTHER IDs - <br /> TYPE 8#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _[D MONITORING C1 HOLLOW STEM DIA OF BOREHOLE_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> _E]EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNE$S TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _13 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 ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _(J INJECTION(.e.Nr Spmaa ozones❑HAND AUGER GROUT SPECIFICATIONS <br /> —❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS; CONDUCTOR CASING❑No[:IYes:Casing Dia:T Casing Depth:_ Boring Die:__ <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUc710N METHOD:(CHECK ALL THAT APPLY) <br /> a #OF WELL(S)TO BE DESTROYED Q OVER-BORE DIAMETER OF enc Teale INCHES TO DEPTH OF See Table fT <br /> WELL IDS: SVE-033 end SVE-032 Q PRESSURE G ROUT TO DEPTH OF sea Table FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Neal Cement(94 lb bag/6.6 gallonEaler ❑EXPLOSIVES FROM TO FTBELOWSURFACE <br /> TREMIE TYPE TO BE USED:pp AUGERS [:jHOSE PIPE N MUSHROOM CAP AT(23—FT)-.L FT BELOW SURFACE <br /> COMMENTS Tables.figures access agreement and data for pressure grouting 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 /> Regulationvall app llca/bIP,C,alifornia laws. / <br /> Signed �'- L-'� ` Title/Company Project Geologist 167ifo SY,lir <br /> Print Name Timothy Davis Date 8/22/2014 <br /> It- , <br /> LQ,EPARTMENTUSE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS IITre /y #b4r <br /> WORK PLAN DATED J LL IC9, 15/ <br /> APPLICATION ACCEPTED BY • yogi&,e DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM E N TS/CONDITIONS: <br /> MACCOUNTINGONLY: AID# FACFEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE/� REQUEST PR#$130, �,(�� eC 3 �Y LmKNMe U`ZZ.-14 SR#607OTPi�() 3?0 RO# <br /> 3600) <br /> PPI <br /> (2900) <br /> C-57 WC t/ WAIVER AiK- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC_tom_ <br /> EHD 29-01 7/24/14 WELL PERMIT APP <br />