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r • SAN .JOAQUIN COUNTY • FILE COP Y <br /> oPq!tl.N.. <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> �'• 600 East Main Street, Stockton, CA 95202-3029 ��Qtf�� <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:WWW.siaoV.oralehd v <br /> 4doaN <br /> WELL & BORING PERMIT APPLICATION ..: 19 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH <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 co RV[PES <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental HeSlj<J�'l ' nt. <br /> 678 North Wilson Wa Fremont Street Stockton 520 141-290-14 <br /> Site Location &ss Street City Zip APN <br /> Property Elizabeth Perry P.O Box 1131 Stinson Beach 94970 415-868-1139 <br /> Owner Address City Zip Phone <br /> C-57 Contractor Cascade Drilling Address 3632 Omec Circle CityRancho CordoveLic 938110 Phone 916-638-1169 <br /> Consultant/Sub Cntr AEI Consultants Address 2500 Camino Diablo City Walnut Creek Lic 654919 Phone 925-746-6000 <br /> Billable Party AEI Consultants Address 2500 Camino Diablo City Walnut Creek Zip 94597 Phone 925-746-6000 <br /> GIS Coordinates:X37-57-42.28"N Y 121-16'22.45"W <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ®SOIL BORING IDs SBl, SB2, SB3 <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER r� <br /> —❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS §?HOSE ❑PIPE U <br /> 3_I&SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) Cb <br /> INJECTION(i.e Air Soame.Ozone)❑HAND AUGER GROUT SPECIFICATIONS W <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE ` <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia' <br /> COMMENTS: Boring SB1 to 50 feet bgs and SB2 and SB3 to 20 feet bgs. Backfill with neat cement grout_ <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 [I OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT O <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE C <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑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 pre ed this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and It Is lifornia Laws. <br /> Signed -----d Title/Company Program Manager/AEI Consultants <br /> Print Name Bryan Campbell Date 3/16/12 <br /> ® DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS G '7 4 4J(L54Ai 4)4V 5h7 ,CTIPA l <br /> WORK PLAN DATED MAZdHof Z. <br /> APPLICATION ACCEPTED BY J.`f oYJ�(u" DATE REA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE 3.2G-I Z <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUE/ST// PDR#C� <br /> 29ds $125, / /25 i _ _/ SR# ( q58 / <br /> RO# <br /> d 3�5 �7S W (3500) <br /> PR# <br /> 2900) <br /> C-57_ WC WAIVER /U n C57 LETTER OF AUTHORIZATION TO SIGN PERMIT // ENCROACHMENT DOC AIq <br />