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P. .la. SAN JOAQUIN COUNTY MAY 0 6 2015 <br /> ENVIRONMENTAL HEALTH DEPARTMENTNVI LOP <br /> RONMEN ITIGATION <br /> 1868 Hazellon Avenue, Stockton, CA 95205-6232 PERA�yIT/5N TIHV <br /> "7 µa Telephone-(209) 468.3147 Fax. (209)468-3433 Web www.Bfgov.org/Bh =� ------ - <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANTINVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appicahon IS hereby made to San Joaquin County for a permit to construct and/or instal;the work described This application is made in compliance with San <br /> Joaquin Co.,ity Development Title Chapter 9-1115 3,and the Standards of the San Joaquin County Environmental Health Department <br /> Site Location 414 W Or MLK Jr Blvd_ Cross Street _S Lincoln City/Slate _Stockton,CA Zio 95206 APN_165-030-04_ <br /> Property <br /> Owner- �� I LW V�kh Mu,� Address _PO Box 690236 ." CKy/Stale Stockton,CA_Zip_95.269 Phone Lx✓ <' J`[`'/ ij`i <br /> C-57 Contractor National EWP_ Address I'?/,/ � ,06eiCI"./ i l/�pY Cdy/Slale t a Lk C?S i[oUb Phone 51,9 - 3C.-b L$� <br /> Consultant/Sub Cntr_SUntec Address 3017 Kilgore Rd,Ste 100_ CBy/State Rancho Cordova,CA Lic Phone 916-364.0766 <br /> Billable Party _Stanlec Address _3017 Kilgore Rd.Ste 100_ C6y/Stale _Rancho Cordova.CA Zio 95570 Phone 916-384-0708 <br /> GIS Coordinates.X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> giNEWWELLISORING(CPT,GEOPROSE,HYDROPUNCH HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> R"ELLIDs r'n 0u - 7 y -21, A, <br /> 0 OTHERIDs <br /> TYPE d 9 OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> � Q MONITORING 0 HOLLOW STEM DIA OF BOREHOLE 0 MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA, <br /> _O EXTRACTION Vapor/Water 0 HAMMER/DRNEN CASING THICKNESS; :V,ed 1`44— TYPE OF CASING ❑STEEL ❑PVC ED OTHER <br /> _O SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL -'r_ TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE <br /> _O SOIL BORING O PUSH POINT 1GP/CPT) GROUT SEAL PUMPED 12Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 Fn <br /> _O INJECTION a&.&jUM CYmel O HAND AUGER GROUT SPECIFICATIONS i1 r 4, / %9 11' <br /> _O OTHER. 0,0THER. Fa u{. APPROX BORING DEPTH_ 'l 0 iOLTEO TRAFFIC BOX OR ❑STOVE PIPE <br /> pONDUCTOR CASING 0 No 0 Yes Casing Dia Ca"Depth A�!4 Boring Dia <br /> COMMENTS. <br /> NOTE: OFFSITE WELLS A BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKL Tp( KATAPPLYI ) <br /> _#OFWEL /`S)TOSE DESTROYED OVER-BORE DIAMETER OF $„_plCt1ES TO DEPTH CFL-{- _ <br /> WELL IDs. S IT't ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS i ' , " O EXPLOSIVES FROM Ta FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED n AUGE S F1 HOSE no PIPE ❑MUSHROOM CAP AT L>3 FT) FT BELOW SURFACE <br /> COMMENTS .' S-61C CLf--via-- T a —�Mo F <br /> 5 WORKING DAYS NOTICE RcwJIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that 1 have prepared this application and that the work will be done In accordance with San Joaquin County Ordinances, Rules and <br /> Regulations, pplicahle C 0.j2n1V <br /> Signed Title/Company <br /> Print Name 0 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS � C' <br /> WORK PLAN DATED Tµ'l ZL" ` <br /> APPLICATION ACCEPTED BY DATE ISSUED S AREA� � <br /> GROUT INSPECTION BY. '. i- ale FINAL INSPECTION BY/ DATE <br /> DESTRUCTION INSPECTION BY � DATE 77T— <br /> COMMENTSICONDITIONS: �- <br /> ACCOUNTING ONLY: AID# 1 FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RD# INVOICE <br /> REQUEST PR# <br /> A9,C k $ 130x CoSC�r cx=� 'S 3b 3 rs SR* <br /> SInow <br /> 35D0 1"ZL <br /> zRO <br /> tloa �3L6y9 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT COC <br /> FHn7115 "",A WFII PFRMIT APP <br />