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a r • <br /> P•"•IN• SAN JOAQUIN COUNTY • FILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT -LO P <br /> "'• ` SITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> Telephone:(209)468-3147 Fax:(209)468-3433 Web:www.sioov.oro/eh <br /> /FOR <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 fora permitto 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 SBB West Weber Avenue _Cross Street Nunn Lincoln Soeet _ City/State smcnon,CA Zip_05202 _ APN 137-37042 <br /> Property UEast weber 95203 (209)9374311 <br /> Stockton ROA aW,M,n,CA <br /> Owner_ _ Address Avenue City/State Zip_ _Phone <br /> C-57 Contractor Grepa pdnin9 aTas9np _ Address 1950 Howe Rd. City/State McNnez,cA Lic as51s9 Phone(e3s)alsseoo <br /> ConsulfantlSub Cnt slam.,con.e9np Ssnkes,m,. ldress �3an K119ore Rd.sunem0 City/State Renono Lic Phone.(ets)es1-w0o <br /> conova,CA <br /> Billable Party Address City/State Zip Phone <br /> GIS Coordinates:X 377 s(s� Y ` I' <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> x NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> D SOIL BORING IDs <br /> BWELL IDs <br /> x OTHER IDs_San vapor Probes:UPSV-7 em UPsv4. <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _[I MONITORING - ❑HOLLOW STEM DIA:OF BOREHOLE 3-1.ra _ D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> Cl EXTRACTION:Vapor/Water D HAMMER/DRIVEN CASING THICKNESS 0.2s-ineh diameter_TYPE OF CASING: O STEEL D PVC 0X OTHER Tenon _ <br /> SOIL VAPOR PROBE D MUD ROTARY DEPTH OF GROUT SEAL-1 a.We _TREMIE TYPE TO BE USED: D AUGERS D HOSE D PIPE <br /> _❑SOIL BORING D PUSH POINT(GPI CPT) GROUT SEAL PUMPED:D Yes D No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _D INJECTION ae arsosen, oonel 1HAND AUGER GROUT SPECIFICATIONS-Not App9aNe <br /> _D OTHER: D OTHER: APPROX.BORING DEPTH_"ftbgs SX BOLTED TRAFFIC BOX OR O STOVE PIPE <br /> CONDUCTOR CASING H No D Yes:Casing DI.: Casing Depth: Boning Dia:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS 8r 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 DOVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: E)PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:I]AUGERS ❑HOSE El PIPE [3MUSHROOM 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 1 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. Asouate sdenast slantec consu9ing semoes,Inc <br /> Signed Title/Company <br /> Print Name Tony Gl9lini Date_1n2ns <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT N FILE-SITE ADDRESS <br /> $$ • <br /> WORKPLAN DATED , Zoy <br /> APPLICATION ACCEPTED BY DATE IS <br /> GROUT INSPECTION BY M.�C �/ FINAL INSPECTION BY L :M�"�- DATE�A�' <br /> DESTRUCTION INSPECTION B7"/ " DATE U <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 2805 <br /> $130K ( 4/53 `t77o �Oa1Q (-Z4-/5' sR# 7iy37 <br /> RO# <br /> 3500 <br /> PR# <br /> 7-7- 2900 <br /> C-57 WC WAIVER -57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC of-_ <br /> EHD 29-01 7124/14 WELL PERMIT APP <br />