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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> � LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:www.sioov.oro/ehd UNIT IV <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. k f. W <br /> Site Location 53ci ST Cross Street «IUn-G1t 57 City S1`0c-k-Ttr1 ZIP aSZUS APN <br /> Property <br /> Owner GIT'/ C* 116�0 1 Address 9-\«A1S OF t, -I (6eEIF IAp <br /> �ity Zip r1ri:Uj Phone (20q)937-93 e <br /> C-57 Contractor FSE Cop{' Address 1232 ALICE 5T STC A City wncP; AND Lic 9060 Phone C53o)(ofol-3600 <br /> Consultant/Sub Cntr Address City Lic Phone <br /> Billable Party. AAP-"A'D Address Srirt o^y Gp, SIF_ 3co City 1+IRLNttT cfK ip �i(S�'T- Phone C`125�'L�r-I- IIDC� <br /> GIS Coordinates:X y <br /> Com( NST! CTION WORK TO BE PERFORMED- <br /> NEN WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> S❑,.SOIL BORING IDs <br /> WELLIDS MW " 2H <br /> ❑OTHERIDs . VJ-2 i. MW�30 I�1 J-3i A!-D "Uva2-- <br /> TY�PE/&#OF WELLMORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> t�Ly MONITORING HOLLOW STEM DIA.OF BOREHOLE 1 <br /> -� ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA'. <br /> _0 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL Id <br /> PVC 0 OTHER <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL-'t(02 VARIG`+TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE 0 PIPE <br /> _0 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION(,s Ai,Soaroe Ozone)0 HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: ❑OTHER'. APPROX.BORING DEPTH n' " VAK16G [dBOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING©No 0 Yes:Casing Dia: Casing Depth: Boring Dia'_ <br /> COMMENTS:�t.I"#�E SBP, A1fA�1-I>=9 �toF ANP w'U. r-tJC-11UL r'(1 �J y tgcgiAM F-t' WS-t•L- < t+ 1}1.0 L-f1�N �pE'c-(FI CATIONS <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION—METHOD:(CHECK ALL THAT APPLY) <br /> ---#OF WELL(S)TO BE DESTROYED ❑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 TOFT BELOW SURFACE <br /> CO M TYPE TO BE USED:❑AUGERS El HOSE ❑PIPE ❑MUS HROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> NTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certi ha I ha prepa d this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations, nd a I a li rnia Laws. <br /> Signed Title/Company <br /> Print Name F�MMUNI'6 Date I/9/ <br /> _ DEPARTMENT U E ONLY <br /> SITE MAP IN UNIT IV FI E ITE ADDR SS <br /> WORK PLAN DATED �J ' �� LU I <br /> APPLICATION ACCEPTED BY DATE ISSUED / I 'Z AREA�Sj��] � <br /> GROUT INSPECTION FINAL INSPECTION BY DATE L <br /> DESTRUCTION INSPECC TION Y LATE <br /> COMMENTS/CONDITIONS: O ^S1d) - „6 .6U <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# <br /> p q REOUEST PR# INVOICE <br /> A?ai $ 125x s 6zC- 4?/--,>Ocscep 9-(Lt IZ SR#oo 150 <br /> �/�7. I�- 3500 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />