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SLI" • SAN JOAQUIN COUNTY • FILE COP Y <br /> T. ENVIRONMENTAL HEALTH DEPARTMENT <br /> '^� LOP <br /> ` ' 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATIC N <br /> o Telephone: (209) 468.3147 Fax: (209) 468.3433 Web:www.sigov.org/ehd 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 8 in <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 531 W.Yosemite Avenue Cross Street Rose Lane City/State Manteca/CA ZP 95336 APN 219-311-08 <br /> Property John&Ann Christensen Trust 349 Scenic Place Manteca/C <br /> Owner Address City/State ''Zip 95337 Phone(209)239-764__ <br /> C-57 Contractor Gregg Drilling Address 950 Howe Street Martinez/C <br /> City/State f'Lic 485165 Phone(925)313-580 <br /> Consultant/Sub Cntr Ami Adini&Assoc. Address 4130 Cahuenga Blvd., Ste 113 City/State Los Angelek/�A Phone(818)824-810 <br /> Billable Party Ami Adini&Assoc.. Inc. Address 4130 Cahuenga Blvd., Ste 113 City/State Los AngelesZip 91602 Phone(818)824-81' ! <br /> GIS Coordinates:X 37.797977 Y -121.222287 CA <br /> a l uC fiT— ongl u e <br /> CONSTRUCTION WORK TO BE PERFORMED* <br /> I] NEW W ELL/BORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑ SOIL BORING IDs <br /> El WELL IDs MW17 1 we 5 <br /> ❑ OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _m MONITORING IN HOLLOW STEM DIA.OF BOREHOLE110_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA; <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASINGTHICKNESS Schedule 40 5751 OF CASING: ❑STEEL �]PVC ❑ OTHER 4A <br /> —0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL=Annul r TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ❑ E <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Ye5 93 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _I]INJECTION(i e.Air Swrae.O_anel❑HAND AUGER GROUT SPECIFICATIONS Bentonite Ce=BOLTED <br /> — <br /> _❑OTHER: ❑OTHER: gPPROX.BORING DEPTH MW17A:3P:MW 1OX OR ❑STOVE,' <br /> CONDUCTOR CABING�I No❑ <br /> Yes <br /> CasinBoring Dla: <br /> COMMENTS Well construction per attached Well Construction Dia ram. <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APP Y) <br /> _#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SUR <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SUR E <br /> TREMIE TYPE TO BE USED:El AUGERS ❑ HOSE El PIPE El MUSHROOM CAP AT L3 FT) FT BELOW SUR,�CE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I haveyyrepared f1r�application and that the work will be done in accordance with San Joaquin County Ordinances, Rule€}atid <br /> Regulation II '_Cabl a fa laws. <br /> Signed ?/ z SIGN HERE TklelCompany <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS y2Q (J `105fr-117 A Ue- /t p;A,Ire W <br /> WORK PLAN DATED 0, p p f 2 sw4w <br /> .APPLICATION ACCEPTED BY ,I -YO�}Kuu-r /�/p,TE LED o2- _AREA 1I6' <br /> GROUT INSPECTION BY FINAL INSPECTILyI tsY/Q DATE 14 E <br /> DESTRUCTION INSPECTION BY DATE_ `1 <br /> COMMENTS/CONDITIONS: - <br /> ACCOUNTING ONLY: AID 9 FAC# ---- <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOIFI <br /> REQUEST PR# <br /> QUI S125x f /2 — /D 77 (?cliurs / 2y-/� SR# 5O2- -- <br /> RO# <br /> (3500) <br /> PR# <br /> 2900 <br /> C-;7 <br /> WC _1GWAIVER 1V I$ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT (/ENCROACHMENT DOC +- 1 <br /> EHD 29-01 5,'09!12 ---•-` <br /> WELL PERMIT'IAP^ <br />