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TYPE & if OF WELL/BORING <br />MONITORING <br />0 EXTRACTION: Vapor/ Water <br />D SOIL VAPOR PROBE <br />01 SOIL BORING <br />INSTALLATION TYPE <br />Da HOLLOW STEM <br />ID HAMMER/DRIVEN <br />0 MUD ROTARY <br />0 PUSH POINT (GP/ CPT) <br />ID INJECTION (Le ,Ar Scams. Ozonel 0 HAND AUGER <br />1:1 OTHER: 0 OTHER: <br />COMMENTS: <br />-RECEIVED <br />7 <br />APR 1 8 Z014 <br />ALTIGIALOTHN EC; <br />Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.siqov.orgENVI/ehdPRE°44 UNIT IV <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 <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 County Development Title, Chapter 9-1115_3, and the Standards of the San Joaquin County Environmental Health Department. <br />Site Location 3931 N. Wilson Way Cross Street E McAl 1 en Rd. City/State Stockte., CA hp 95205 ApN 132 - 020 - 08 <br />Property <br />Owner <br /> <br /> <br />Address City/State <br />C-57 Contractor nrazan ,. Resociates, inn. Address 215 W. Dakota Ave City/State Clovis, <br />:::razan ,;, r-,sso,iates, <br />Consultant/Sub Cntr;., Address 215 W. Dakota Ave City/State Clovis, <br />Billable Party Address City/State <br />GIS Coordinates: X -121.9662424 y 37.994697 <br />CONSTRUCTION WORK TO BE PERFORMED: <br />MI NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) <br />MISOIL BORING Ds 31 <br />0 WELL IDs <br />0 OTHER IDs <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Zip Phone <br />cALic 499908 Phone (559) 348-2200 <br />cALic 499908 Phone (559) 348-2200 <br />Zip Phone <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 4 . 5 "D MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL El PVC CI OTHER <br />DEPTH OF GROUT SEAL 1 0 TREMIE TYPE TO BE USED: 0 AUGERS Cl HOSE IDPIPE <br />GROUT SEAL PUMPED: 0 Yes C511 No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />GROUTSPECIFIUMONS 94 # Type I-II Cement/6 Gallons Water <br />APPROX. BORING DEPTH 10 feet 1:1 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br />CONDUCTOR CASING 1:1 No 0 Yes: Casing Die: Casing Depth: Boring Dia: <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />I hereby certify that <br />Regulaticits, a <br />Signed <br /> <br />Title/Company Professional Geologist, iCrazan & Associates, Inc. <br /> Date 4/14/14 <br />AREA <br />DATE <br />DATE <br />DESTRUCTION MET11012:_(cHEcK ALL THAT APPLYI <br />0 OVER-BORE DIAMETER OF INCHES To DEPTH OF FT <br />WELL !Ds: 0 PRESSURE GROUT To DEPTH OF FT BELOW SURFACE <br />GROUT SPECIFICATIONS 0 EXPLOSIVES FROM TO FT BELOW SURFACE D MUSHROOM CAP AT (a3 FT) FT BELOW SURFACE <br />DESTRUCTION WORK TO BE PERFORMED: <br /> #01 WELL(s) TO BE DESTROYED <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />COMMENTS <br />5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />ave pr aired • ,application and that the work will be done In accordance with San Joaquin County Ordinances, Rules and .. <br />ca Calif - s. <br />Print Name Martin oth <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS <br />WORK PLAN DATED <br />APPLICATION ACCEPTED BY DATE ISSUED <br />GROUT INSPECTION BY FINAL INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />COMMENTS/CONDITIONS: <br />ACCOUNTING ONLY: AID # FAC # <br />PE CODES FEE INFO AMT REMITTED CHECK if RECV'D BY DATE SERVICE <br />REQUEST <br />RO if <br />PR # INVOICE <br />$ 125 x SR# <br />RO if <br />(3500) <br />PR # <br />(2900) <br />C-57 WC <br /> <br />WAIVER <br /> <br />C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />WELL PERMIT APP END 29-01 5/09/12 <br />