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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> ¢• Z1 <br /> . TIGAT <br /> 600 East Main Street, Stockton, CA 95202-3029 T ION <br /> . •.. - :...;P'• Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.si4ov.or9le <br /> A��FOR� <br /> WELL & BORING PERMIT APPLICATION NOV 15 2011 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL H <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is m,89Wh" <br /> Joaquin County Development Title,Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 2335 East Miner Ave Cross Street E Street city Stockton zip 95205 APN 153-260-44 <br /> Property <br /> Owner Jerry Henderson Address 14434 Navajo Way City Manteca Zip 95336 Phone <br /> C-57 Contractor Advanced GeoEnvironmental,Inc. Address 837 Shaw Road City Stockton LIC 680227 Phone 209467-1006 <br /> Consultant/Sub Cntr same as above Address City Lic Phone <br /> Billable Party same as above Address City Zip 95215 Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> M NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ®SOIL BORING IDs B1 132 B3 B4, 135, B6 <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1.25" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 20-50'bsg TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE p PIPE <br /> 6 ®SOIL BORING ®PUSH POINT(GP/CPT) GROUT SEAL PUMPED: ❑Yes x❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ❑INJECTION(i.e.Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS Type 1/11 Neat Cement <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 20'and 50'bsg ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: Four soil borings to 20' bsg and two soil borings to 50' bsg <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that ave prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and applica CaH16r-MA Laws. <br /> Signed - Title/Company President/Advanced GeoEnvironmental. Inc. <br /> Print Name obert E Mart Date 11/14/2011 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FSITE ADDRESS 23 <br /> IL <br /> WORK PLAN DATED G1 t/0 o <br /> APPLICATION ACCEPTED B DATE ISSUED I L I I AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: '5�S <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> nnC, REQUEST PR# <br /> 1 <br /> t b5 $125xI �(i ll SR#Ob63�j <br /> 7 J (3500) <br /> (z 00)�53�SSb <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />