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au�" SAN JOAQUIN COUNTY C ) <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> �.•:� 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> �A. :•;�� Telephone: (209) 468-3147 Fax:(209)468-3433 Web:www.sioov.oroleh <br /> cre gayf <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 /> Cross Street <br /> Site Location <br /> 374 Lincoln Center West Benjamin Holt City/State Stockton,CA Zip 95207 AP(,OB to <br /> ownrProperty mo wLmftsm5.2-eN mrP Address 374 Lincoln Center City/State StocktT on,CA Zlp 95207 phone 209-078-9200 <br /> Owner <br /> C-57 Contractor <br /> National E.W.P Address 1861 Meeker Ave CilylState Rlchmond,CA Le 953646 _Phone 510-236-5202 <br /> Consultant/Sub Cntr Address City/State Lic_Phone <br /> Zip 95670 phone 916-637-6048 <br /> Billable Party <br /> Geosyntec Consultants Address 3042 Gold Canal Drive Suite 201 City/State <br /> GIS Coordinates:X 121.321172`WY 38.008905'N <br /> a�fz YI <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE— 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water 0 HAMMER/DRNEN CASING THICKNESS TYPE OF CASING: Cl STEEL 0 PVC ❑ OTHER <br /> —0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> _0 SOIL BORING 0 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ❑INJECTION fle AIS W-0 0 HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: [-]OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> T CONDUCTOR CASING 0 No 0 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 ALLTHAT APPLY) See Tabla <br /> ea #OFWELL(S)TOSE DESTROYED ®DIVE 10REDIAMETEROF See TeNe INCHES TO DEPTH OF FT <br /> WELL IDS S—T"'- ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Nmjcemn1i(%4ibbaglseganonswaiar ❑EXPLOSIVES FROM _TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:0 AUGERS—[]HOSE ❑ PIPE ❑MUSHROOM CAP AT(>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,aqd all applicable California laws. <br /> Signed <br /> � �� Title/Company Protect Geologist /�ir l..Oynl[t <br /> Print Name <br /> Timothy Davis Date 8/2212014 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITEADDRESrS t tQ d- EN hfb'CT 7AVKTav <br /> WORK PLAN DATED J-L L. / 2/ pa <br /> APPLICATION ACCEPTED BY J • '7t4KK DATE ISSUED S• ZS y�I AREA_! G Y 7 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITI ONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# <br /> a <br /> 10)- $13o X ,Z ltXvGo \ 22335 2 QotwiL'Z 8-Z2-'y SR# ;b <br /> 290 3 3 0 390 Ro# <br /> 350D <br /> PR# <br /> 2900 <br /> C-57 V WC V WAIVER A.1 C-57 LETTER OF AUTHORIZATION TO SIGN PERMITyENCROACHMENT O WELLPERM <br /> EHD 29-01 7/24/14 <br />