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PA• � SAN JOAQUIN COUNTY COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Lop <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> • �`' <br /> :(209) 468-3454 Fax:(209) 468-3433 Web:www.si4ov.orc1/ehd UNIT IV <br /> 4 •!F p fla�P <br /> � <br /> I WELL & BORING PERMIT APPLICATION <br /> R <br /> OWELLS 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 16777 Howland Road Cross Street E.Loise Ave. City, Lathrop Zip 1,103o APN 198-140-04 <br /> Property <br /> Owner J­ ow Address 16T77 Howland Road City, Lathrop Zip `I i73-W Phone 209-858-2511 <br /> C-57 Contractor Cascade Drilling Address 3632 Omec Circle City Rancho Cordova Lic `1;TI'V Phone y+b ki�y—►IGfI <br /> Consultant7Sub Cntr ARCADIS Address 950 Glenn Drive,Ste 125 City, Folsom Lic Phone <br /> Billable Party ARCADIS Address 950 Glenn Drive,Ste 125 City, Folsom ZipI Phone <br /> Ur��v 916-985-2079 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) <br /> ®SOIL BORING IDs IA da^�■ tSJ�•1�SS �r.`'t c�✓ctJ�Clc� <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3-inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ®HAMMER/DRNEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEA' Ift bgs TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _N SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:p Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION 6.e.AlrS arue O an 119 HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX BORING DEPTH 1L.1 b9s ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING'j�No❑Yes:Casing Die: 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 prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. <br /> Signed Title/Company Task Manger/ARCADIS <br /> Print Name Brett Krehbiel Date 12/10/2012 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS :27 /70 111Ll4 tiL� LAL2 <br /> WORK PLAN DATED It, 2,,Ll <br /> 00 1 AftAXj*g =go-- <br /> APPLICATION ACCEPTED BY {n Ku laI DATE 1 /G <br /> U FA <br /> DATE <br /> GROUT INSPECTION BY FINAL INSPECTION BY � <br /> .,. <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> q REQUEST PR# <br /> I CJ 5 $125 x / C0tz0Ur6C (2•72,/ S R# LP Z 7�v <br /> 29U 3�� RO# <br /> 3500 <br /> PR# <br /> 2900) <br /> C-57 WC (i WAIVER_;V i1 C57 LETTER OF AUTHORIZATION TO SIGN PERMIT C/ ENCROACHMENT DOC wA <br />