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lail A <br /> SAN JOAQUIN COUNTY <br /> 7. <br /> ?�. .a ENVIRONMENTAL HEALTI-I DEPARTMENT <br /> • • ' `` 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov•org/ehd .,NIT Iv <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 /> 8700 Thornton Ave Davis Rd Stockton,CAZ 95209 072-420-15 <br /> Site Location Cross Street City/State ip APN <br /> Property Richard Sola 10341 Creek Trail Circle Stockton,C/� 95209 <br /> Owner Address QCi /State ip Phone 7 nZ-3 7'C-ylz Z <br /> SCy 00f2 /state 9COV Phone � 8-- <br /> C-57 Contractor "a mss -�-� <br /> Consultant/Sub Cntr Cook Environmental Address 1485 Treat Blvd.,Ste 203A City/State Walnut CreekCA 921387 phone 925-478-8390 <br /> Billable Party <br /> Richard Sola Address 10341 Creek Trail Circle City/State Stockton,CAZ1p 95209 Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPRODE,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 NA ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> —nEXTRACTION:Vapor/Water beHAMMER/DRIVEN CASING THICKNESS NA- 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 /> ZO.SOILBORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM�FREE FALL DEPTH IS 30 FT) <br /> —E]INJECTION(i a Air Sparge, [IOzonel HAND AUGER GROUT SPECIFICATIONS ��'- '� Lam/r-OA <br /> _❑OTHER: ['^Tui R: APPROX.BORING DEPTH 3 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> JNDUCTOR 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) <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 L3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have pre ared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all a aCYli rnia laws. <br /> Signed �"? <br /> E _ Title/Company President/Cook Environmental Services,Inc <br /> Print Name <br /> Tim Cook Date 6/12/2013 <br /> DEPARTMENT USE ONLY <br /> )QW <br /> I <br /> APPLICATION ACCEPTED B`: YO(gkt(1PI_ __ DATE PR <br /> — <br /> GROUT INSPECTION BY V FINAL INSPECTION BY TE Z 7� <br /> DESTRUCTION INSPECTION BY r _ DATE <br /> COMMENTS/CONDITIONS: _ <br /> ACCOUNTING ONLY: AID�1- FAC# SERVICE RO,1 <br /> PE CODES — INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST ST PR# INVOICE <br /> SR# 67Y8/ <br /> RO# <br /> > (3500) <br /> PRft <br /> (2900 <br /> C-57_"_ WC _��WAIVER.—ktL C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT �' ENCROACHMENT DOCS✓ _ <br /> WELL PERMIT APP <br /> EHD 29-01 5/09/12 <br />