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OOP V If <br /> tt15 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT 4 LOP <br /> �• 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATIONUNIT IV <br /> Telephone; (209) 468.3454 Fax: (209) 468.3433 Web:www.sigov,orolehd <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 Sen <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location -47.'D 9 0 __V' Cross Street S32C�� glYA City -MLzip-jEjzle APN <br /> Property 916'1$M'Sl 4 <br /> Owner L2n► 1 eaci *`G Q ti14�Address (34Sl&MOSM�I Nf l0'6iey AoSCV1�le Zip953H} Phone <br /> C-57 Contractor PeneCoee Address IIN �kltc_e Sty City 1a i_ic !Phone 530'641.3111+W <br /> ConaultsntlSubCntr �jRADIS Address I 10 Rn City 1'----c Phonallb-381*' 1$� <br /> Billable Party hkArD1S US Address � �� Clty Ip 80129 Phone_ <br /> GIS Coordinates:X 37, 737� Y^r21.YfA co <br /> CONSTRUCTION WORK TO BE PERF RMED- <br /> NI W WELUBORING(CPT.GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER) <br /> ❑ SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION ATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _(]MONITORING ❑HOLLOW STEM DIA-OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS _ _TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER O <br /> _E)SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP!CPT) GROUT SEAL PUMPED:❑Yee ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION fl.e.Alr Some.ozone)❑HAND AUGER GROUT SPECIFICATIONS _ <br /> _❑OTHER: ❑OTHER: APPROX BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yee:Casing Dia: Casing Depth: Boring Die: <br /> COMMENTS: <br /> NOTE; OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTR CTIQN METHOD:JCHEKALL THAT APPLY <br /> _%p_lt OF WELL(S)TO BE DRSrROYEU OVER-BORE DIAMETER OF*oxnO ANOiES TO DEPTH OF <br /> WELL IDS: FY oLt-F-rJiLaA -I&bU 0 PRESSURE GROUT TO DEPTH of FT BELOW SURFACE <br /> GROUT SPECIFICATIONS 401t "Y`V"I``'v ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED Q AUGERS HOSE N PIPE ❑MUSHROOM CAP AT(_>3 FT) FT BELOW SURFACE <br /> COMMENTS --- — <br /> 5 WORKING DAYSNOTICEREQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby cart)y that I have pr pard this application and that the work will be done In accordance with Sen Joaquin County Ordinances,Rules and <br /> Regulaiiv s, nd all applicab 0 C Iltornle Laws. <br /> Sign — Title/Company 0� 'Pc C- <br /> Print Name _ 7vi t- Esc Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS2a C, <br /> WORK PLAN DATED /0 -6-11 <br /> APPLICATION ACCEPTED BY I, ; O 19X14 In DATE ISSUED_. 1I rid--If AREA 16 <br /> GROUT INSPECTION BY FINAL INSPECTION BY. DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RU# INVOICE <br /> r� Q��/� REOUE3TPR# <br /> $125 x8lfJ SR# <br /> lI(ZS `fit 7 c�2 GI- 3-rl 3a o ) <br /> �9 <br /> PR#03 2900 C o Wq <br /> C-57. k WC lj WAIVER CS7 LI=TTER OF AUTI IC}RATION TO SIGN PER U IT - -- ENCROACf-IME=NT DOC <br />