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Is W111111%rows W 5111060 <br />SAW JOAQUIN COUNTY DEC 0 4 2017 <br />—ter ENVIRONMENTAL HEALTH ©EPARTMEM& LOP <br />1858 Hazelton Avenue, StIaddon, CA 95205-6232 PERMI /W&LITIGATION <br />Telephone: (209) 468-3147 Fax: (289) 468-3433 Web: WWW.siaOV.Qr_gMd1 UNIT IV <br />Cy <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 instail the vmf t described. This application is made in compliance with San <br />Joaquin County Development Tine, Chapter 9-1115.3. and the Standards of the San Joaquin County Environmental Health Department. <br />She Location 17100 Murphy Parkway Cross Street D`Arry ParkwayLathrrop, CA <br />City/Stete ZIP 95330 AFN 198-012-009 <br />Propeowner ASPJRWM Pr rf a—,, of 8t1 Address 1 UQ C zirt+"sxd Ave.. ,gie. City/State Cor rWCA Zip 94520 Phone 192 1, 674=-s4po <br />C-57 Contractor Garde 0411ing Address3OWDukIth Street <br />CitylStale Wast Saw.. CA.ic 938110 Phone (91 t%} 638- t 169 <br />CotfsultanHSub Cntr srusca Ais$oc., irlc. Address PO Box 332 City/Stale Roseville, CALio GEG#1948 Ptlorle (916) 6,77.1471) <br />BINabta Parry Brusca Assoc, Inc. Address PO Beat 332r� City/StMe Roseville, CA Zip5501 9Phone (916)677--1470 <br />GIS Coon ina6sa: X 37.806 Y _121 287 +� Oft o-S'ck , sex. Ztgc :!.S A*, cF+ uw <br />0 SOIL BORI <br />0 WELL 10k <br />0 OTHER IDr <br />(CPT, GEOPROBE. HYDROPUNCH. HAND -AUGER, OTHER) <br />TYPE & 0 OF WEIM ORING INSTALLATION TYPE CONSTRUCTION §=FICAT)ONS <br />_0 MONITORING 3 HOLLOW STEM DIA. OF BOREHOLE 6„ ❑ MULTIPLE CASINGS (3 MULTI-LEVEL WELL CASING DIA: <br />_0 EXTRACTION: Vapor/ Waller ❑ HAMMER/DRtVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />_0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL 2" TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />_O SOIL BORING 0 PUSH POINT (GPI CPT) GROUT SEAL PUMPED: Q Yes C NO (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />_O INJECTION O HAND AUGER GROUT SPECIFICATIONS neat cernent grout <br />2' [(OTHER' Sai Ger "" Y° *OV Q OTHER:, APPROX BORING DEPTH 10' <br />❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />NDUCTOIR CATNNG ❑ NPC DaYeej� a: C;Wp Baring Dia: <br />COMMENTS. Installation of 2 sail gas monaofing walls and abar rrarrvt a orris we 7v Bn a�nc T1�711 I tt+i ` vr„ <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />_# OF WELLS) TO BE DESTROYED [OVER -BORE DIAMETER OF _ A rMCHES TO DEPTH OF 20 FT <br />WELL IDS; 11i�1 ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br />GROUT SPECIFICATIONS 0 EXPLOSIVES FRpu TO FT BELow SURFACE <br />TREMIE TYPE TO BE USED: @ AUGERSHOSE 0, PIPE El MUSHROOM CAP AT (>3 FT) FT BELOW SURFACE <br />COMMENTS Abandonment of existing earl qas mart+torinq well <br />5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />I hereby certity that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordirwrices, RUIes and <br />Regulations, *#d all appgcabis California lays. <br />Signed _ <br />Print Name <br />SITE MAP 144AIT IV FILE - SITE <br />WORK PLAN DATED I <br />APPLICATION ACCEPTED BY <br />GROUT INSPECTION BY <br />TitlelCornpany President i BrIma Assountes. Inc. <br />Date 111271'17 <br />DEPARTMENT USE ONLY <br />DATEISSUED <br />FINAL INSPECTION BY <br />DESTRUCTION INSPECTION BY DATE <br />COMMENT311CONDITIONS: <br />AREA <br />DATE <br />ACCOUNTING ONLY: <br />AID #A -Cr—,"' `- t <br />FAC if <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK d <br />RECV'D BY <br />DATE <br />$ERYICE <br />REQUEST <br />s <br />PRO <br />INVOICE <br />jr K2— <br />w <br />t�o37 07 <br />PR 9 1 ")41,;� <br />lMvl(�< <br />1.:-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC _ - <br />EHD 29-01 SM12 WELL PERMtTAPP <br />