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4R4utN � �/ (J <br /> SAN .IOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> � 1..:• :5/ <br /> Telephone: 209 468-3147 Fax: 209 468-3433 Web:www.siaov.ora/eh UNIT IV <br /> .uFgga. P ( ) ( 1 <br /> WELL & BORING PERMIT APPLICATION <br /> STK '/ 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 fora 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 West Benjamin Holt City/Stale Stockton,CA Zip 95207 APN 9741029 <br /> Property + -- <br /> Owner UnJ—b a Address 1810 East Hazelton Ave City/State Stockton,CA Zip 95207 Phone 209-468-3000 <br /> C-57 Contractor National E.W.P Address 1961 Meeker Ave City/State Richmond.CA Llc 953646 Phone 510-238-6282 <br /> ConsultanUSub Cntr Address City/State Lic Phone <br /> Billable Party Geosyntec Consultants Address 3042 Gold Canal Drive Suite 201 City/State R'M°"�'oA Zip 95670 Phone 916-637-8048 <br /> GIS Coordinates:X 121.321172'W y 38.008905'N <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&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _Q EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> —Q SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _O SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION(1,Ai,Sp,,o%o )F1 HAND AUGER GROUT SPECIFICATIONS <br /> _O OTHER: ❑OTHER: APPROX BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS; CONDUCTOR CASING❑No(j Yes:Casing Dia:T Casing Depth:_ Baring Dia:_ <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> -STRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED MOVER-BORE DIAMETER OF See TMb INCHES TO DEPTH OF See Table FT <br /> WELL IDs: F.ee Table O PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS N.MCemenr(941bbag/S-Bgallwswaw ❑EXPLOSIVES FROM TO FTBELOWSURFACE <br /> TREMIE TYPE TO BE USED:M AUGERS HOSE-*PIPE 9 MUSHROOM CAP AT(>3 FT) Sae Table 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,a11d all applic le California laws. <br /> Signed vJ�- �� — <br /> Title/Company Protect Geologist / Uj(c, 4 / <br /> Print Name timothy Daw-S <br /> Date 8/22/2014 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS A/ - ar $ice irvr/ <br /> WORK PLAN DATED -..J ulL /8' zp/S( <br /> APPLICATION ACCEPTED BY - /dia�'k H� DATE ISSUED 'zS '7y AREA �G94 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS ICO N DITI O NS: <br /> ACCOUNTING ONLY: AID# - FAC# <br /> PECODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> qo2 $130X .223352 C-*vW 8•Z2-/q sR# 70 3 <br /> 9o3 50 390 RO# <br /> (3500 <br /> PR# <br /> 2900 <br /> C-57 f/ WC WAIVER J7- C-57 LETTER OF SIGN PERMIT V ENCROACHMENT AUTHORIZATION TO T DOC <br /> EHD 299 017124—/14 <br /> WELL PE MITAPP <br />