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?�;--•c���� SAN JOAQUIN COUNTY <br /> C 00 <br /> ENVIRONMENTAL HEALTH DEPARTMENT L <br /> LOP <br /> �% 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> �4s7'-Ra" Telephone:(209)468-3147 Fax:(209)468-3433 Web:www.siaov.org/ehUNC_ <br /> Fo <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 West Benjamin <br /> Property �--Cross Street 1 min Holt City/State Stockton,CA Zlp 95207 APN 9741029 <br /> Owner ww,° P•ni..rTowsm,..G.,v,u¢�+com Address 374 Lincoln Center Stockton,CA 95207 <br /> National E.WP City/State Zip Phone 209-478-9200 <br /> C-57 Contractor 1961 Masker Ave <br /> Address CI /State Riahmand,CA <br /> Consultanf/Sub Cntr h' L(c 953646 Phone 510-236-6282 <br /> Address City/State Dc <br /> Billable PartyGeosyntec Consultants Phone <br /> Address 3042 Gold Canal Dr've Suite 201 City/State "'""°c"°°"''e" Zip 85670 Phone 916-637-8048 <br /> GIS Coordinates:X 121.321172"W Y38.008905'N <br /> roti p/%p 3 —/.2•/ 'i22G <br /> na r nuc.I ION WORK TO BE PERFORMED <br /> ❑NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> —0 MONITORING Q HOLLOW STEM DIA.OF BOREHOLE <br /> _Q EXTRACTION:Vapor/Water ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _Q BOIL VAPOR PROBE El MUD ROTARY DEPTH OF GROUT SEAL <br /> _Q SOIL BORING TREMIE TYPE TO BE USED: Q AUGERS Q HOSE Q PIPE <br /> ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:Q Yes Q No(MAXIMUM FREE FALL DEPTH IS 3D FT) <br /> —0 INJECTION g.e.ar 5oaroeO r❑HAND AUGER GROUT SPECIFICATIONS <br /> _Q OTHER: Q OTHER: <br /> APPROX,BORING DEPTH Q BOLTED TRAFFIC BOX OR <br /> ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING Q No Q Yes:Casing Die: Casing Depth:_ Boring Dia: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD•rcHECK ALL THAT APDL n <br /> s� #OF WELLS)TO BE DESTROYED I]OVER-BORE DIAMETER OF s.P Tams Be.Table <br /> WELL IDs: 6ea Table INCHES TO DEPTH OF <br /> GROUTSPECIFICATIONS Neel Camenl(91166eg ISE gallons wamr ❑PRESSURE GROUT To DEPTH OF Fi BELOW SURFACE <br /> TREMIE TYPE TO BE USED.®AUGERS ❑HOSE ❑PIPE EXPLOSIVES FROM TO FT BELOW SURFACE <br /> COMMENTS Tables,fl urea,access a reement attached ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 1 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,aryN ap applicablgCalffornla laws. <br /> Signed <br /> Z&'= G� <br /> Print Name Timothy Davy Title/Company Project Geologist <br /> Data 8/22/2014 <br /> p EPARTMENT USE ONLY <br /> SITEMAPIN UNIT IV FILE-SITE ADDRESS {F /L rSw0f) <br /> WORK PLAN DATED �„ <br /> APPLICATION ACCEPTED BY DATE ISSUED 'ZS'/° <br /> GROUT INSPECTION BY AREA(/ <br /> 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# <br /> qREQUEST PR# INVOICE v <br /> $13oX3 U D 2233SL nau:E2 v ZZay SR# 703 <br /> 2°(U 390 3 O RO# <br /> 3500 <br /> PR# <br /> C-57WC 2900 <br /> EHD 29-01 7/24/14 <br /> WAIVER_ � - C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _,ENCROACHMENT DOC <br /> WELL PERMIT PP <br />