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oP4'!y. s SAN JOAQUIN COUNTY t <br /> a ^" ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> X SITE ION <br /> 1 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> •..- ;_ Telephone: 209) 468-3454 Fax: 1209) 468-3433 Web:www.siaov.ora/ehd - <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 14749 N.Thornton Rd. Cross Street Thornton Rd./Kettleman Ln City Lodi Zip 95245 APN GJST5 a2G -3/sl/I <br /> Property Ton Khatirine 14749 N.Thornton Rd. Lodi 95245 209-368-8100 <br /> Owner y Address City Zip Phone <br /> BC2 Env. Address 1150 W.Trenton Ave., City Orange Llc 969758 Phone 714-744-2990 <br /> C-57 Contractor 209-467-1006 <br /> A.G.E. 8 Shaw Consultant/Sub Cntr Address City Stockton Lic 680227 Phone <br /> Billable Party <br /> A.G.E. Address 837 Shaw Rd. City Stockton Zip 95215 Phone 209-467-1006 <br /> GIS Coordinates:X 038.1116c) Y - r� <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 WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS I]MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water Cl HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _l]SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> —17 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _l]INJECTION('a it Soerae Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _[I 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 /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS - <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:{cHECKrALL THAT APPLY) 150' <br /> _Q__#OF WELLS)TO BE DESTROYED IN OVER-BORE DIAMETER of INCHES TO DEPTH OF FT <br /> WELL IDs: MW-7,-8,-9,-10,-11,-12,-13, -14,-15 ❑ PRESSURE GROUT To DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: f-1 AUGERSC7 HOSE PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS SEE WORKPLAN DATED 09 MA 014 <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,and all applicable Ca <br /> Signed f<I _Title/Company PROJECT MANAGER/A.G.E. <br /> Print Name TIMOTHY J. ELLAR Date 03/20/2015 <br /> nDEPARTMENT USE ONLY <br /> SITE MAP IN UNITIVFILE-SITEADDRESS /A/7t/'7 'r1*RIV'?ZVV k An 400)/ <br /> WORK PLAN DATED A449r� 13, �n13 <br /> APPLICATION ACCEPTED BY J, f9*jU41-'l DATE ISSUED 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'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 0 2_ $ 1/I o $ 3-23. , SR# 7/8 75 <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 A,' WC ✓ WAIVER It"4- - C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT 1-f ENCROACHMENT O P� <br /> BRM <br /> EHD 29-01 07/28/10 <br />