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T_ �/ <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT P <br /> SITE ION <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> -.:.; Tele hone: 209)_468n3454 Fax: 209)_468-3_433 Web._www.sidov.orglehd__ <br /> - <IFORa <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. - (16, <br /> Site Location 14749 N.Thornton Rd. Cross Street city Thornton Rd./Kettleman Ln ci Lodi Zip 95245 APN QHS 02, 3/31/i <br /> Property Ton Khatirine 14749 N.Thornton Rd. Lodi 95245 209-368-8100 <br /> Owner y Address Phone <br /> City Zip <br /> BC2 Env. 1150 W.Trenton Ave., City Orange Lic 969758 Phone 714-744-2990 <br /> C-57 Contractor Address <br /> Consultant/Sub Cntr <br /> A.G.E. Address 837 Shaw d. City Stockton Lic 680227 Phone 209-467-1006 <br /> Billable Partye� <br /> A.G.E. Address 837 Shaw Rd. Cit, Stockton Zip 95215 Phone 209-467-1006 <br /> GIS Coordinates:X 035.1 t Sw Y _�V i 3151 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYOROPUNCH,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❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION(,,,.A,,Soarae.ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _O 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:(CHECK ALL THAT APPLY) 150' <br /> 9 #OF WELLS)TO BE DESTROYED ®OVER-BORE DIAMETER of 6" 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 �qq nn ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO <br /> WORKPLAN DATE6 09 SE 0,4 ❑MUSHROOM CAP AT(>3 Fr) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 1 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 applicableCa- rn' laws. <br /> Signed 7 a _ Title/Company PROJECT MANAGER/A.G.E. <br /> Print Name TIMOTHY J. ELCLI LAR Date 03/20/2015 <br /> rsDEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS ���7W7 ��*W W Rn R71t I 4001 <br /> WORKPLAN DATEDNI14Nr� /3 If l s <br /> APPLICATION ACCEPTED BY j d*XHH't 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 /> yo $ t l l c� 3-23• / sR# 7r8�S <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57_,- WC ✓ WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC f-,4 <br /> EHD 29-01 07/28/10 WELL PERMIT APP <br />