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n4VrN� <br /> SAN JOAQUIN COUNTY <br /> �~ 2\ ENVIRONMENTAL HEALTH DEPARTMENT <br /> Q. LOP <br /> `\ • 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> T4 s ( / <br /> Telephone: 209) 468-3147 Fax:(209) 468-3433 Web:WWW.Siaov.orG/eh UNIT IV <br /> WELL & BORING PERMIT APPLICATION <br /> CjTRf 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 Cross Street West Benjamin Holt City/Slate Stockton,CA Zip 95207 APN 9741029 <br /> Property �— <br /> Owner s.n.m.w any Address 1810 East Hazelton Ave City/Slate Stockton.CA Zip 95207 Phone 209-468-3000 <br /> C-57 Contractor National E.W.P Address 1861 Meeker Ave City/State Richmond,CA Lk; 953646 Phone 510-236-6282 <br /> ConsuitanVSub Cntr Address City/State Lic Phone <br /> Billable Party Geosyntec Consultants Address 3042 Gold Canal Drive Suite 201 City/State a'" Coi° GA Zip 95670 Phone 916-637-8048 <br /> GIS Coordinates:X 121.321172°W Y 38.008906'N <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 B,#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> _C3 EXTRACTION:vapor/Water 0 HAMMER/DRIVEN CASINGTHICKNESS TYPE OF CASING: ❑STEEL O PVC ❑ OTHER <br /> —Q SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AVGERS EJHOSE 13PIPE <br /> _0 SOIL BORING ElPUSH PONT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —O INJECTION(le Ar a_ame Orn 10 HAND AUGER GROUT SPECIFICATIONS <br /> _O OTHER: ❑OTHER: APPROX BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia:T Casing Depth:_ Boring Dia:. <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> -STRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD•(CHECK ALL THATAPPLYI <br /> #OF WELL(S)TO BE DESTROYED OVER-BORE DIAMETER OF see Table INCHES TO DEPTH OF See Table FT <br /> WELL IDs: Sea Table 9 PRESSURE GROUT TO DEPTH of <br /> GROLJTSPECIFICATIONS Neataememr bbagl5-egalbnswh,r Fi BELOWSURFACE <br /> TREMIE TYPE TO BE USED: ■ AUGERS ❑EXPLOSIVES FROM To FTSELOW SURFACE <br /> COMMENTS Tables.Tiaures.access aereemen[attached <br /> ❑HOSE PIPE V MUSHROOM CAP AT(>3 FT) See Table FTBELOW SURFACE <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,atild a``ll appp/lic le Califomla laws. / <br /> SignedTitl <br /> Project / ul <br /> --.--3—� e/Company 1 Geologist <br /> Print Name Timothy Daws <br /> Date 8/22/2014 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE_ADDRESS / /- <br /> WORK PLAN DATED ...1(,(/,_ 20/ <br /> APPLICATION ACCEPTED BY - yOlasCct H� DATE ISSUED •Z'j-/y AREA <br /> GROUT INSPECTION BY 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 O BY DATE SERVICE RO# JNVOICEREQUEST PR#q02 $130X 7gp .223352 'LsxfvlLtR 8-z2-lq SR# 70 3�3 oto 390 RO# <br /> (3500PR# <br /> (2900C-57� WC WAIVER�� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT < ENCROACHMENT DEHD 29-01 /24/14 <br /> WEL <br />