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RECEIVE) <br /> SAN JOAQUIN COUNTY <br /> JUN O 3 <br /> 2015 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> fi�n�,, ► *`NVIRONMENT��I � OGATiON <br /> ■�Y4 '. • 600 East Main Street, Stockton, CA 95202-3029 PEI�MlT�SI=N <br /> Telephone: (209)488-3454 Fax: (209) 468-3433 Web:www.siclov.ora(ehd SNIT IV <br /> (jFoei <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 Councy Develo ment Title,Chapter 9.1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 8 I Vest Lane cross street Bourbon Street city Stockton Zip 95204 APN 117-030-01 <br /> Property Steven and Kimberly Kellogg Etal <br /> Owner Address 736 Mariposa Road#F City Modesto Zip95354 Phone <br /> C-57 ContractorA�dvdavnced GeoEnvironmentakddress 837 Shaw Road City Stockton Lic 680227 Phone 209-467-1006 <br /> Consultant/Sub Crttranced GeoEnvironmenW6dress 837 Shaw Road City StocktonLic 680227 Phone 209-467-1006 <br /> Billable Pa Advanced GeDEnvironmental <br /> Party Address 837 Shaw Road City Stockton Zip 680227 Phone 209-467-1006 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ®NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ®SOIL BORING IDs SV1, SV2,SV3, SV4 <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 125 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/water ❑HAMMERORIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> 4 )b SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL UP t0 15' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes [9 No(MAXIMUM FREE FALL DEPTH Is 30 FT) <br /> _❑INJECTION li.e_Air soarne.ozones❑HAND AUGER GROUT SPECIFICATIONS Type 1111, neat cement <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH Up to 15' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING[INo E]Yes:Casing Dia: Casing Depth: Boring Dia: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THATAPPLYI <br /> #OF WELL(S)TO BE DESTROYED ElOVER-BOREDIAMETER 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,an II appU t71e_C ifornia laws. <br /> Signed Title/Company President,Advanced GeoEnviron mental <br /> Print Name Obert Marty Date 02/24/2015 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS_ 3 Fs0$ IA o--)± jn=C&e_'c�_ <br /> WORK PLAN DATED -s 1-15— <br /> APPLICATION <br /> -1SAPPLICATION ACCEPTED BY A A4c DATE ED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION B DATA(� <br /> DESTRUCTION INSPECTIO BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST I PR# <br /> ,RIO s $13ox 3 .1 34 o•ao !17-3.6 SR# &595' <br /> x903 3q0• 31.vo 1 1 X3.6 5 5 3S�t <br /> z#) l q <br /> C-57 WC WAIVER G57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 <br /> WELL PERMIT APP <br />