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ff,. ...aV11 SAN JOAQUIN COUNTY tj <br /> o ,. o <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> N.. .. . .,.. I •{ <br /> • '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> �;•.- ;o <br /> Telephone: 209) 468-3147 Fax: (209 468-3433 Web: www.sigov.orglehd UNIT IV <br /> A ( ) <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES T 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 <br /> 1 Title,Chapter 9-1115.3,and the Standards of the San Joaquin County rrEnvironmental Health Department, 6 <br /> Site Location Z?-55V 4i- tYf dV�ross Street Ir.lb" CitylStateJ�4ip� APN f49-069 55 <br /> Property 3,�'Eb zj-$;/F <br /> Owner Address P'P• AC 'K City/Stah� * Zip�J�1 Phonerr�9 <br /> C-57 Contr �r11ji` Address ZZDAl, ift 1Md, LiC gala Phon 'j� W4600 <br /> Consuitantl / f�rVU1QdRJ� �tlAddress IU,N�► f' 1JY"� F� �{���j Li,& S30 Phon gib &9 <br /> Billable Party UliQlJyketr lith 7 AdLdCress /O9✓rfi'W c� SKr�c Cityl tate«s !C Zip D Phon 303 �7} S/ . <br /> GIS Coordinates:X 27 y3Dg1 Y-14Qt.2k6y.< <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING iDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ©HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMERIORIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS 0 HOSE 0 PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED: ❑Yes ❑ No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION ii-e-&r Sparge.Ozone)[]HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE <br /> COMMENTS: CONDUCTOR CASING 0 No ElYes:Casing Dia: Casing Depth: Boring Dia: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PER ORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY <br /> #OF WELL( ) O = TROYED ' 1/ Ik v1l1 a /��St[rG Crate' OVER-BORE DIAMETER OF -^ O INCHES TO DEPTH OF 19-66'FT <br /> W LL IDS:i 'Z 3 SW- 2 PRESSURE GROUT TO DEPTH OF ,t5' �' FT BELOW SURFACE <br /> GROUT SPECI CA ISN we EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE PIPE ;MUSHROOM CAP AT(?3 FT) F31-P FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have pared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all dppl. abl California I s. <br /> Signed 7 Title/Company �14! <br /> Print Name Date <br /> lot <br /> i <br /> DEPARTMENT USE ONLY f/ <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS L [ �Z� �, QL40-on-- <br /> WORK PLAN DATED OPP <br /> APPLICATION ACCEPTED BY 9�9 - — DATE ISSUED 11 l <br /> AREA 9!27 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE p <br /> D <br /> 7 / �^ J / REQUEST PRS#y $ 125x11 ! 47—J r 2 S fwd"lCi IJ ZVl SR#60108 -7 <br /> ((3 00) <br /> PR# <br /> - _ (zs . - -- I <br /> C.-.57. WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />