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— <br /> .o <br /> SAN 10AQUIN COUNTY DRIGINAL <br /> I x ENVIRONMENTAL HEALTH DEPARTMENT SOP <br /> :.• _: . <br /> 600 East Main Street, Stockton, CA 95202=3029 SITE MITIGATION <br /> .. ._ Telephone: <br /> xo ;a�� p ene: (209) 468-3'147 Fax:(209) 468-3433 Web:www. UNITIV <br /> �ciov.ora/eh <br /> WELL & BORING PERMIT APPLICATION , <br /> FOR WELLS AND BORINGS USED'FOR CONTAMINANT INVESTIGATIONS AND REM EDIATION �� <br /> I <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 JUpli 2 9 w�it01l <br /> Joaquin County Development Title,Chapter 9-1916.3,and the Standards of the San Joaquin County Environmental Health Depa <br /> �re7e�- Center <br /> Site Location Cross Street W. 3rd Street p' <br /> Property City Stockton Zip_95�n6� _ f LL <br /> Owner Ismael Rivera Address X717 S. Center St, f <br /> City Stockton Zip 95206. Phone '209-462-3374 <br /> C-57 Contractor Gre Drillin AddressQw, y Cd5,7,-4$516 <br /> Cit Martinez LI ....7 .--:..., ,.. <br /> Consultant/Sub Ct�ntr eY onu Address 210 L Sand Bari Rd.City Columbia Lic 'hone 925-313-5800 <br /> Billable PartyA de ul X2236 Phone F,1R—�R�_1 �n3 <br /> Address 210 W. Sand Bank Rd-City-0011—biaZips`Phone 6i8-281-154 3 <br /> GIS Coordinates:X 37.935 Y-121.2 6 <br /> CONSTRUCTION WORK TO BE PERFORMED- <br /> ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDS <br /> ❑WELL Ips <br /> ❑OTHER IDs <br /> I: TYPE&#OF WELLIBORING INSTALLATION 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 <br /> �❑SOIL VAPOR PROBE. ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTHIS30 FT) <br /> `❑INJECTION(Le.AirSoaroe.Ozone/❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALL THAT APPLY <br /> #OF V- TO BE DEy ROYED f ' —� '.®OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: P "d'r MW— —3A� -MW—S"� <br /> }' MW MW�5A', L® PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT 66LOW SURFACE <br /> TREMIE TYPE TO BE USED:.E3AUGERS ❑HOSE ®PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE i <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 accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all a Wnderbson <br /> Ii is laws. <br /> Signed —Title/Comm _ Project Manager — PSC <br /> r Print Name Paul E. Date <br /> t <br /> '► DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED <br /> ' APPLICATION ACCEPTED B DATE ISSUED a�a AREA <br /> GROUT INSPECTION BY - Z�ALNSPECTION-BY 9 DATE <br /> DESTRUCTION INSPECTIO <br /> COMMENTSICONDITIONS:4.4-9,,h1� &� '� •/� <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# ' RECV'D.BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> /a SRS 004.5. <br /> ,��"4 _ $125x - X00.� 5 d9`3� � <br /> 0,3 37�� ,� 5-� � 4�/a Roo 00��T_ <br /> PR# + <br /> 2900 t <br /> C-57 WC WAIVER C-67 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC_ <br /> WELL PERMIT APP <br /> EHD 29-01 01113112 / <br />