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SAN JOAQQ UlN COUNTY <br /> ENVIRONMENTAL HEALTH:DEPARTMENT LOP <br /> SITE MITIGATION <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> •-_ ; Telephone: {209}468-3454`Fax:{209} 468.3433 Web:www.s' Ov-Or 1 <br /> E—GL, I <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS'AND REMEDIA �S-z01z <br /> NON-REFUNDABLE PERMIT.EXPIRES 1 YEAR FROM.DATE,ISSUED ;tff <br /> Application is hereby made to San Joaquin County for a permit to construct andlor inslah the work described:_This applicatioMep: <br /> Develo ment Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health DITr`SERVICE.S <br /> Joaquin County p <br /> SJC Ili ht Of-Way E.Calim rna Road Ci Acampo Zip 95220 APN NA <br /> Site Location g Y Cross•Street .' Y.. city <br />! Property pp Boz 1810-1810'E.Hazelton Ave. Stockton 95201 209)469-3000 <br /> Owner SJC Dept.of Public Works Address _ City Zip Phone <br /> C-57 Contractor Cascade Drilling,LP Address 3632 Omec Circle City Rancho Cordova Lic 938110 Phone (916)638-1169 <br /> ConsultantlSub Cntr <br /> Cardno-EERI Address 60t N.McDowell Blvd. 'City Petaluma, Lic AIC10 611383 Phone (707)766-2000 <br /> Billable Party <br /> Cardno-ERI Address..601 N.McDowell Blvd. City.''Petaluma Zip 94954 Phone (707)766-2000 <br /> GIS Coordinates:X 38.2169018 Y -121.2687844: <br />�i 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 ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS MULTI-LEVEL WELL CASING DNA: <br /> } _❑EXTRACTION:Vapor!Water ❑HAMMER/DRIVEN CASING THICKNESS° TYPE OF CASING: ❑STEEL`❑PVC El.OTHER <br /> �❑SOIL VAPOR PROBE [I MUD ROTARY DEPTH OF GROUT SEAL TREMNE TYPE.TO BE USED: ❑AUGERS ❑HOSE:'❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL'.PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION ❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR"❑STOVE PIPE. <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> I NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS' <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> ti 3 #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: MW9,MW I0,MWS El PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Type I,TI.PortlandCement;-517o entomte by wt.© EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:El AUGERS El HOSE-L3 PIPE Ill MUSHROOM CAP A, L3FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE.REQUIRED JAFTER PERMIT,;ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify t hav pared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,a d ap ble California Laws: <br /> Signed Title/Company.V Sr.Staff Geologist <br /> Print N Jim Donohue Date / <br /> DEPARTMENT USE ONLY pp <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS -26736-9- �.1 t <br /> WORK PLAN DATED L' <br /> APPLICATION ACCEPTED BY Y;L6 r.a rY?g=c:q' DATE IS 1 59 <br /> GROUT INSPECTION BY FINAL INSPECTION BY' /Q <br /> 'DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: S r -S VII Ad W -Z a' ress vre. q re afl ' <br /> ACCOUNTING ONLY: AID# - FAC <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE- RO 0 INVOICE' <br /> REQUEST PR# <br /> - JSl/Z $125x 3 y 3 'rr, I.s. S7 7/�-/.� .SR#J 0t'i-$30 <br /> Jlsir. RO# <br /> 35-o .3 376_,00 - 3 75,•0 0 3500 244 <br /> C-57 WE - WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOG­ <br />