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• • FILE COPY <br /> oa I"• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> Q: <br /> e: a 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> d4.., P•• Telephone:(209)468-3147 Fax:(209)468-3433 Web:WWW.siaov.oro/eh UNIT 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. 137-370-01 <br /> 802 West Weber Avenue Nadh Lincoln Slmet 55203 <br /> Site Locatlor�" Cross Street City/State slocidon,CA Zip_ APN <br /> Property I+dr�+ulEfaa A� Af-C � - <br /> Owner_E.J.W11Ia=Pncedy Management _ Address P.0.eu7185 City/State 6wW.n,CA Zip_95203 _Phone (209)4734U2 <br /> C-67 Contractor Gregg Ddnmg&Tes9ng _ Address ,1950 Howe Rd. City/Stale Medina,CA Lic 4BSIes Phone(925)313-3500 — <br /> ConsultantJSubCntsmnlecconsuMngsemces,lnc ,dress .30171mgore RcSunc100 City/State Rancho Lic Phone.(9'e)eB14w00 _ <br /> camaw,CA <br /> Billable Party Address City/State Zip Phone <br /> GISCoordlnates:X 4 —f2( �.9 0 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> x NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> D SOIL BORING IDs <br /> WELL IDs <br /> x OTHER IDs_Souvagor Pmbea:APSV-n mrough APSV-1B. <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE sPnih _ 0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION:Vapor/Water D HAMMER/DRIVEN CASING THICKNESS 02 4noh diameter_TYPE OF CASING: D STEEL 0 PVC 0x OTHER Tenon _ <br /> Di SOIL VAPOR PROBE [I MUD ROTARY DEPTH OF GROUT SEAL_I a.bgs _TREMIE TYPE TO BE USED: O AUGERS O HOSE D PIPE <br /> _D SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION(I a Av scarce.ozone,HX HAND AUGER GROUT SPECIFICATIONS_Not ApplimWe <br /> _O OTHER: 0 OTHER: APPROX.BORING DEPTH—"n NIS Ex BOLTED TRAFFIC BOX OR O STOVE PIPE <br /> CONDUCTOR CASING E No 0 Yes:Casing Dia: Casing Depth:_Bonng Dia:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:POHECKALL THATAPPLY) <br /> #OFWELL(S)TOBE DESTROYED ❑OVER-BORE DIAMETER O= INCHESTODEPTHOF FT <br /> WELL IDs: O PRESSURE GROUT TO DEPTH OF FTBELOWSURFACE <br /> GROUT SPECIFICATIONS O EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:0 AUGERS 0 HOSE 0 PIPE 0 MUSHROOM CAP ATL3 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 applicableCalifornialaws. Associate sclenun,siemecconsmtmg semus,Inc. <br /> Signed ,u: Title/Company <br /> Print Name Tonyclglin, Date laws <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITEADDRESS 'rte <br /> WORK PLAN DATED /e/ <br /> APPLICATION ACCEPTED BY J' R'btgll DATE I —�"RRl!R <br /> GROUT INSPECTION BY FINAL INSPECTION BY G '#/'•C� <br /> DESTRUCTION INSPECTION DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY !1! <br /> INVOICE <br /> $130X 45 3 26 �'4n�r� <br /> 2Qo 3 4a <br /> C-57WC r/ WAIVER A0-57 LETTER OF AUTHORIZATION TO SIGN PERMIT Y ENCROACHMENT DOCS <br /> EHD 294)1 724/14 WELL PERMIT APP <br />