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NDS <br /> 51� • • � r, l I� <br /> SAN .10AQUIN COUNTY �l <br /> ... <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> `"a ".• Telephone: (209)468-3147 Fax:(209)468-3433 Web:wwwsiaov.ora/eh <br /> UNIT IV <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 permitto 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 Clty/State Stockton,CA Zip 95207 qpN 9741029 <br /> Property <br /> Owner Address 374 Lincoln Center City/State Stockton,CA Zip 95207 Phone 209-478-9200 <br /> C-57 Contractor National E.W,P Address 1961 Meeker Ave City/State Richmond,CA Lic 953646 Phone 510-236-6282 <br /> Consultant/Sub Cntr Address City/State LTG Phone <br /> Billable Party Geosyntec Consultants Address 3042 Gold Canal Drive Suite 201 City/State Pindio Cei°°""" Zip 95570 Phone 916-637-8048 <br /> GIS Coordinates:X 121.321172°W Y 38.008905"N <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(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 Q HOLLOW STEM DIA.OF BOREHOLE_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _Q EXTRACTION:Vapor/Water I]HAMMERIDRIVEN CASINGTHICKNESS TYPE OF CASING: Q STEEL ❑PVC ❑ OTHER <br /> _Q SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _0 SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _Q INJECTION 0 Ar Soerae@onel❑HAND AUGER GROUT SPECIFICATIONS <br /> —0 OTHER: ❑OTHER: APPROX,BORING DEPTH ❑BOLTED TRAFFIC BOX OR Q STOVE PIPE <br /> COMMENTS; CONDUCTOR CASING❑No Q Yes:Casing Dia: Casing Depth:_ acting Dia:,_ <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:fcHECKALL THATAPPLYi <br /> e' *OF WELLS)TO BE DESTROYED Q OVER-BORE DIAMETER OF see Tea- INCHES TO DEPTH OF See Table FT <br /> WELL IDS: See Table El PRESSURE GROUTTO OEPTHOF FTBELOWSURFACE <br /> GROUT SPECIFICATIONS Neet camera fsa coney lss yslmae»•mer EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:H AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>_3 FT). FT BELOW SURFACE <br /> COMMENTS Tables,figures access aoreemant 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 /> Regulatfons,ark aU appll abl California laws. / <br /> Signed mit!-,- G��7 Title/Company Project Geologist <br /> y�,Sy.1fcC <br /> Print Name Timothy Davis f <br /> Dale 8/22/2014 <br /> PM <br /> DEPARTMENT USE ONLY rv1 <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 1� �� {- /V /-/o % SjYklSw <br /> WORK PLAN DATED r <br /> APPLICATION ACCEPTED BY -� -fp/•'1t'.t.f e'r^ DATE ISSUED -Z'S`/° AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> DATE . <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICON DI TI O NS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> REQUEST PR <br /> # <br /> qQ�- 2z $130X3 U D 27- 3SL mQVMQ- Zzay SR# 70-3 <br /> 2 �7 QDRO# <br /> 3 0 3500 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER_ ILa_ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC <br /> EHD 29-01 7/24/14 <br /> ed(Z SIIti - I hr V4" WELL PERMIT PP <br />