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L <br /> SAN JOAQUIN COUNTY <br /> " <br /> ENVIRONMENTAL HEALTH DEPARTMENT LO <br /> • 1868 Hazelton Avenue, Stockton, CA 95205-6232 ENVI;, -10,ATION� <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:wWW.siqoy.orcrF d -/SERVUNIT IV <br /> 0 <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 18754 State Rt(Fl2ci)26 Cross Street lone Street City/State Linden Zip 95236 APIN 105-170-48 <br /> Property <br /> Owner Sam Orlando Address 2201 South B Street City/State Stockton Zip 95206 Phone 916-708-4999 <br /> C-57 Contractor Advanced GeoEnviron Address 837 Shaw Road City/State Stockton Lic 680227 Phone 467-1006 <br /> Consultant/Sub Cntr Advanced GeoEnvirorAddress 837 Shaw Road City/State Stockton Lic Phone <br /> Billable Party Advanced GeoEnvironmental Address 837 Shaw Road City/State Stockton Zip 95215 Phone 467-1006 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> M NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> [@ SOIL BORING IDs 131 through 1311 <br /> F-1 WELL IDs <br /> n OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _E]MONITORING El HOLLOW STEM DIA.OF BOREHOLE 1.5" (j MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING CIA: NA <br /> EXTRACTION:Vapor/Water [I HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER— <br /> SOIL VAPOR PROBE [3 MUD ROTARY DEPTH OF GROUT SEAL 10-20' TREMIE TYPE TO BE USED: OAUGERS 0HOSE OPIPE <br /> 0 SOIL BORING [N PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes Qg No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _[]INJECTION(i eAir Sparge.Ozone)El HAND AUGER _ GROUT SPECIFICATIONS Portland Type 11 <br /> —0 OTHER: 0 OTHER: APPROX.BORING DEPTH 10-20' 0 BOLTED TRAFFIC BOX OR C:ISTOVE PIPE <br /> CONDUCTOR CASING El No El Yes:Casing Dia:—Casing Depth:_ Boring Dia:_ <br /> COMMENTS: Advancement of 11 soil borings for collection of soil samples <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 0 OVER-BORE DIAMETER OF —--INCHES TO DEPTH OF FT <br /> WELL IDs: E] PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS El EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: E]AUGERS E]HOSE ❑PIPE ❑ MUSHROOM CAP AT(?3 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 all appl' able Califo is laws. <br /> Signed Title/Company Project Scientist/Advanced GeoE nviron mental, Inc. <br /> Print Name Alison Colavita Date 02/06/13 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS H 6 <br /> WORK PLAN DATED EEB RU_1jQ!j 20/ <br /> APPLICATION ACCEPTED BY 0 rikc"V-1 DATE AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY 2-(,N� <br /> DESTRUCTION INSPECTION BY DATE <br /> V <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 /> -5 $125X If C0 CA VL) �1z SR# <br /> 240 3�5 Roo)) <br /> PR# <br /> (2900) <br /> C-57 L/-' WC __(',�AIVER /V C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 1 5/09/12 WELL PERMIT APP <br />