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SAN .IOAQUIN COUNTY <br /> ORIGINAL <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> UNIT IV <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigv.ora/eh <br /> o <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 Count Development StocktA the Oha-ofjter&1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Lowtiot('or f W th and S. Wil W Worth Street/South Wilson Way Stockton 95205 N/A <br /> .4�' ' ross Street City/State Zip APN <br /> Proper„ city of Stockton 625 N. 61 OOrado 5[ocktOn 95203 209-93]-8393 <br /> Owner Address City/State Zip Phone <br /> Aav9ncad Geoenvison.ental Inc 81] Shaw Road Stockton 68013] 209-46]-1006 <br /> C-57 Contractor Address City/State Lic Phone <br /> Advanced Geoenvirooental Inc. 33] Shaw Roed Stockton 68022] 209-467-1006 <br /> Consultant/Sub Crrtr Address City/State Lic Phone <br /> Billable Party AGE Address 837 Shaw Road Clty/State Stockton Zip 95215 Phone 209-467-1006 <br /> GIS Coordinates:X 37r qH 7f 1,1 Y--2-2/I A4 e(59 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELLIBORING(CPT,e EO PROBE,HYDROPUNCH,RAND-AUGER,OTHER) <br /> p SOIL BORING IDs <br /> SIO <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1'2s ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> —0 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL SO' TREMIE TYPE TO BE USED: 0 AUGERS ❑HOSE ©PIPE <br /> 4 El SOIL BORING O PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ®No(MAXIMUM FREE FALL DEPTH IS 30 Fn <br /> _t]INJECTION(i a At Sponge O2.Ga)❑HAND AUGER GROUT SPECIFICATIONS Portland cement (6 gallons Per 94 Its bay) <br /> _O OTHER: ❑OTHER: APPROX BORING DEPTH 5. ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Borirg Dia:_ <br /> COMMENTS: <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 WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER 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 p3 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 Ila icable California laws. <br /> Signed Title/Company AGE/Project Geologi.t <br /> Print Name p/ `1 vlllan,.eva Date 09/26/1.24 <br /> Q <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS O <br /> WORK PLAN DATED R PRI II 2-pi •/ /'l���G,�; <br /> APPLICATION ACCEPTED BY O 6Ku rn DATE IS UED )0"�—� AREAS`/ <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE�l <br /> DESTRUCTION INSPECTION BY DATE 41 <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO All REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST I PR# <br /> 35o <br /> $,3DX 1 0 /c�yoZ CXAu q z6-i SR# <br /> 351)3 3�o (3 <br /> PR# <br /> 2900 <br /> C-57 ✓ WC b WAIVER_4Z 4- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOCy <br /> EHD 29-01 7/24/14 WELL PERMIT APP <br />