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FEE MOM SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT LOP <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br />Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.siciov.orqieh UNIT IV <br />WELL & BORING PERMIT APPLICATION <br />FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEITIL E COPY <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 County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. <br />Site Location 2051 VVest Lane <br />Property <br />Owner Ben Rishwain <br />C-57 Contractor ECA <br />Consultant/Sub Cntr Partner ES! <br />Billable Party Partner ESI <br />GIS Coordinates: X 037. 97,57 y <br />Cross Street Ronald St <br />Address P.O. Box 1567 <br />Address 3011 Twin Palms Dr <br />Address 1017 22nd Ave, Ste 107 <br />Address same as above <br />7 2 1, 28Xio <br />City/StateStocktOn, CAZip 95205 APN 117-090-18 <br />City/State Lodi, CA Zip 95241 Phone 209-481-2676 <br />City/State Aptos, CA Lic 695970 Phone 916-417-6858 <br />City/StateOakland, CALic Phone 510-323-4496 <br />City/State Zip Phone <br />CONSTRUCTION WORK TO BE PERFORMED: <br />[XI NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) <br />RI sou_ BORING IDs B1, B2, B3, B4, B5 <br />El WELL IDs <br />OTHER IDs <br />TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />El MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 2" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION: Vapor/ Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC El OTHER <br />0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE El PIPE <br />5Lgi SOIL BORING 0 PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: 0 Yes 0 No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />0 INJECTION (i.e .Air Sparee. Ozone( 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: RI OTHER: Direct Push APPROX. BORING DEPTH 20 ft (3): 5 ft (2)0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br />CONDUCTOR CASING 0 No 0 Yes: Casing Dia: Casing Depth: Boring Dia: <br />COMMENTS: All borings will be filled after sampling with neat cement slurry usi g pipe tremie <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />Signed <br />Print Name <br />Title/Company Staff Assessor, Partner Engineering & Science, Inc. <br />Date 4/21/15 <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> # OF WELL(S) TO BE DESTROYED El OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br />WELL IDs: CI PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br />GROUT SPECIFICATIONS El EXPLOSIVES FROM TO FT BELOW SURFACE <br />El MUSHROOM CAP AT (3 FT) FT BELOW SURFACE TREMIE TYPE TO BE USED: ID AUGERS El HOSE El PIPE <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 all applicable California laws. <br />Cindy Frickle <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS a.oS ltX51" 1-Ak. S-7 -fzerreou <br />APPLICATION ACCEPTED BY J. CfOitic-6611 <br />WORK PLAN DATED 4PRit. a S, <br />DATE ISSUED Li2et-I1 AREA <br />GROUT INSPECTION BY FINAL INSPECTION BY <br />DATE S <br />DESTRUCTION INSPECTION BY <br />DATE <br />COMMENTS/CONDITIONS: <br />ACCOUNTING ONLY: AID # FAC # <br />PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE <br />REQUEST <br />RO # <br />PR # INVOICE <br />2,10 5 $ 130 x 3 390 v.zia8zc i0Gt evor-R_ L I-2 q -ii- SR# 720 24 <br />RO # <br />(3500) <br />PR # <br />(2900) <br />C-57 sr• WC i/ WAIVER ,t'4- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br />EHD 29-01 7/24/14 <br />"ENCROACHMENT DOC 4/ 4 <br />WELL PERMIT APP