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R <br /> IN. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> t <br /> 1866 East Hazelton Avenue, Stockton,CA 95205-6232 SITE MITIGATION <br /> UNIT IV <br /> •..- Telephone:(209)468.3454 Fax:(209) 468-3433 Web:www.sigov.orglehd <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 ZDD N- wa Cross Street \1J<u�.\ru.'{O'^ City S�It C\L�gT Zip qTZ75 APN .3 -31 :1 <br /> Property �\ � <br /> Owner 5 r ti Address (351x7 ��bLvA L, City —ZIP g _Phone -Ua�_ sZ <br /> C-57 Contractr c �nt Address SD ' �c . City YA7 A\vve-A Lie S T Phone, 'q2-5-313- <br /> or Consultant/Sub Cntr - L Address vA City Llc Phone <br /> Billable Party ��o\L Yom_ Addresos 1,DS 3 City FYY.:•n.�tS _ZIp 24 Phone <br /> GIS Coordinates:X \'Zl° Di w Y <br /> C NSTRUCTION WORK TO BE PERFORMED: ,,'] ! �J <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) �J(/ y5 / <br /> SOIL BORING IDs LLL/// <br /> WELL IDs W\W aq "J— 'a <br /> ❑OTHER IDs <br /> TYPE 8#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'L I%,MONRORING ❑HOLLOW STEM DIA.OF BOREHOLE rI I]MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: <br /> _O EXTRACTION:Vaporl Water O HAMMERIDRIVEN CASING THICKNESS ��. TYPE OF CASING: O STEEL W PVC ❑ OTHER <br /> _.O SOIL VAPOR PROBE 'tMUD ROTARY DEPTH OF GROUT SEAL\7rt K TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE PIPE <br /> _O SOIL BORING O PUSH POINT(GPI CPT) GROUT SEAL PUMPED:A Yes ❑No(MAXIMUM FREE FALL DEPTH I``S 30 FT) \\ \ <br /> _O INJECTION II a Air Swrag Dmnel[I HAND AUGER GROUT SPECIFICATIONS M %F!,I TIV.\'fC-'h�YO <br /> _O OTHER: Cl OTHER: APPROX.BORING DEP,TTp,,H'''' O BOLTED TRAFFIC BOX OR O STOVE PIPE <br /> t� \ CONDUCTOR CASING 9LNo❑Yes:Casing Me:_Casing Depth:_ Bodng Die:� <br /> COMMENTS: V)Jk�\ S;n�d' �Z Weds Susar �-e h.�'....ts� — e'�'�e �.,r: 5,_ +• *�•�.r �o \35 <br /> �S <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS GREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTIONWORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLYI <br /> #0 WELL(S)T0 BE DESTROYED C]OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT To DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE '❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <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 accordancewith San Joaquin County Ordinances,Rules and <br /> Regulations,and a1 (cab al fomia L s. I <br /> Signed �--�—� Title/Company 1 Q o� �o�r t6W <br /> Print Name Date___14 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY as Ku -1 I-r AREA �6 <br /> GROUT INSPECTION BY FINAL INSPECTION BVC$2PL E Z <br /> DESTRUCTION INSPECTION BY DAT <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> RE QUEST <br /> PRO <br /> Z.9� / $125x 2JZ2r, T SR#Wotse <br /> Ro# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 v WC_7WAIVER .ydi• C57 LETTER OFAUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC n/Kl <br />