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--- : EC IVJ FILE COPY <br /> SAN JOAQUIN COUNTY <br /> JAN 0 5 2015ENVlRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> HEJ � Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> 468-3147 Fax: (209) 468-3433 Web:wwwsiaov.orgleh <br /> t�Foa+- PER <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 3081 N.Tracq Blvd Cross Street CitylState Tracy.C Zip 95376 APN 214-18441 <br /> Property Stuart Limited Partncrshi P,O.Bos 370055 La:Vccas.Nv 89137 415-617-5791 <br /> Owner P Address CitylState Zip Phone <br /> C-57 Contractor"1O n.ncoial Cuou,I Assnum`sAddress =011 Tlvin Palms Drive City/Stale APIos.CA Lic 695970 Phone 916-417-6858 <br /> Consultani ' tr Partner ESl Address 2154 Forrunce Blcd.Suite 200 City/Slate lorrance.CA Lic Phone 508.876-'_'660 <br /> Billable Partyl art limited PartnershiP Address RO.Bos 370055 City/State Las View.NV Zip 89137 Phone <br /> GIS Coordinates:X 17045'35,30"N Y 121"26' 11.03"W <br /> 17 7 S -/ y H 34 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLJBORING(CPT.GEBOIthrough <br /> IOII DR -A <br /> PUNCH.HANDUGER.OTHER) <br /> L SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑ MONITORING D HOLLOW STEM DIA.OF BOREHOLE !i-In D MULTIPLE CASINGS❑MULTI-LEVEL WELL CASII4G GIA: <br /> _❑EXTRACTION:Vapor/Water D HAMMER.'DRNEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER. <br /> _D SOIL VAPOR PROBE D N.UD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS D HOSE D PIPE <br /> .�Lm SOIL BORING 19 PUSH POINT(GP/CPT) GROUT SEAL PUMPED.D Yes [9 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _D'NJECTION, ,>,Soai^_e.O,.re [IHAND AUGER GROUT SPECIFICATIONS Neat Cementflr0111 <br /> ❑OTHER. D OTHER: APPROX BORING DEPTH ?S ePI D BOLTED TRAFFIC BOX OR D STOVE PIPE <br /> CONDUCTOR CASING®No D Yes Casing Dia: Casing Depth _ Boring Dia:_ <br /> COMMENTS: ? Interior and T exterior borin^s for soil and temporary -mUndwaler Sample Collection. <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 DEPT H OF FT <br /> WELL IDS: ❑PRESSURE GROUT TO DEPTH OF FT8E1OWSURFACE <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TCI FT SELrivr SURFACE <br /> TP,EMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑ PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS All boring to be sealed/destroyed with¢rout and conereterTsphTll natch <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 appliFlole California laws. <br /> Signed <br /> (4 _I` li Title/Company Proie41Mangger- Partn 'rEngimeringYsyjy�7se Inc. <br /> Print Name Tont A Campbell Date 17. - sc. - I'7 <br /> p �DEPARTMENNT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS�eq TRA�41 IJ40 1?RIKY <br /> WORK PLAN DATED D ECM C <br /> APPLICATION ACCEPTED BY ..1. NOl}KC[W _ DATEI Al <br /> GROUT INSPECTION BY FINAL INSPECTIO14 BY_ A t �D I�.I / <br /> DESTRUCTION INSPECTION BY DATE <br /> (COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY'. _ AID FAC#_ _ 2 <br /> PE CODES FEE INFO AMT REMITTED CHECK# <br /> DATE <br /> SERVICE <br /> 'D BY R <br /> —� RECV1 O# INVOICE <br /> 1 ''. REQUEST _PR# _ <br /> aq o 3 370 (3500) <br /> _i. . . <br /> PRP <br /> (2900) .._ „ <br /> y ✓.b-1'iEfl P/4- C-57 LETTER OF AUTtIDPIZAIIQN TV SIGt4 PLRM:T _-_ ✓ Lh R0A.,HfAENT IJOC_� <br /> - Eh ._, V i '24 14 _ AELL Pc RNill IPP <br />