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4�vc�V E;u <br /> SAN JOAQUIN COUNTY � Auc,Iii zwv <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> w 600 East Main Street, Stockton, CA 95202-3029 iF UN T IVTION <br /> 4 p. Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sinov.o M <br /> L/FORS <br /> leh <br /> WELL & BORING PERMIT APPLICATION S�p <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION P <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED X 5 OIJ <br /> Appliwfion 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 Cross Street City Zip APN <br /> 14749 Thornton Rd. Thornton Rd. & Hwy. 12 Lodi 95245 055-150-26 <br /> Property P.O. Box 1036 Tracy <br /> Mil. S. Padilla �,. 95378 209-832-7780 <br /> Owner nn�� _ Address _7yy,�� City /,�J� Zip Phonen <br /> C-57 ConVactor 45 _ Address ?/W �/T�l �/ Cin NJ Lic�Phone r <br /> Consultant/Sub Cntr Adv. Geo. Env. Address 837 Shaw Rd. City stocton LIC 6e0 z7 Phone 209-467-1006 ff <br /> Adv. Geo. Env. 837 Shaw Rd. Stockton 95829 209-467-1006 <br /> Billable Party Ad-drr/ess G City Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: ' <br /> ®NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> EISOILBORINGIDs P-19, P-20 & P-21 (Soil Strings) & P-22, P-23 (soil vapor probes) <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA.- na <br /> _0 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER NA <br /> x❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 5' & 25'TREMIE TYPE TO BE USED: []AUGERS ❑HOSE [n PIPE \� <br /> x❑SOIL BORING [n PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes [2 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —❑INJECTION fie As Sea,ce 0zone1❑HAND AUGER GROUT SPECIFICATIONS PORTLAND TYPE II �[r' <br /> _O OTHER: ❑OTHERAPPROX.BORING DEPTH 5' & 25' 0 BOLTED TRAFFIC BOX OR ❑STOVE PIPE-�L� <br /> CONDUCTOR CASING® NA No�Yes:Casing Dia: Casing Depth: NA Boring Dia: NA `n <br /> COMMENTS: W <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLYI <br /> 0 OF WELLS)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 w <br /> COMMENTS <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 Cali rnia lawTitle/Company S. <br /> Signed :h <br /> /^1 <br /> 'J Project Manager/Advanced GeoEnvironmental, Inc, vl]\\v <br /> TimothynVellar <br /> Print Name Date Ln <br /> DEPARTMENT USE ONLY LQP� <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY AREA <br /> GROUT INSPECTION BY FINAL INSPECTION DATE,?—/, e <br /> DESTRUCTION INSPECTION BY DATE r <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC It <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR It <br /> 3� $, X Imo" /I 61-14-11 SR# 3704 <br /> So <br /> RD#-- <br /> -- <br /> 3500 <br /> L4 1 --ilMal W1 <br /> C-57 WC WAfVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT C N C N <br /> EHD 25-01 07/28/10 LL PERMfT APP <br />