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SAN JOAQUIN COUNTY <br /> •� y ENVIRONMENTAL HEALTH EPARTMENT LOP <br /> { SITE MITIGATION <br /> 600 East Main Street, Stockton, GA 95202-3029 UNIT IV <br /> Telephone: (209) 468-3454 Fax (209) 468-31.33 Web: www.sigov.orglehd <br /> �f�pRa <br /> WELL & BORING PERMITAPPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT NVESTiGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YE,\R 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 Joaquh i County Environmental Health Department. <br /> WAY <br /> Site Location X3,;3&A57- C.1ART�ross Street Aird Pie' W A Y' ity S�Cff-W Zip 95 5 APN 15137,909 <br /> Property <br /> Owner /I/i¢Q2y/iPAf�HAfZ Address J-� a5.f, c//A g7, 4-1Ay ity <br /> Zip o�Phone Z0 7 �1��� <br /> C-57 Contractor � _�,C [-xp�f aTrvu Address�qja M�cI�&R ASE ity k(,-r- MgAe[� Lic 22332- Phone S/D Z3A 62-32- <br /> Cons uttant/Sub <br /> zSZConsuttant/Sub Cntr C R IA T Address 5lBD f-WX4,S S i SrsjT&11 C ity�M 4ZyYlL[ Lic Phone4�CLLU 0700 <br /> Billable Party C R A Address 5 jOO Pdi-1/S 5 T`iy/%ch ityIF-44iFRYC,'/L LQip g4F6 0<? Phone5-/Z> V Lo 0'7z; <br /> U <br /> GIS Coordinates:X Y F11 r enpir <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDS <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIF ICATIONS <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(GP/CPT) GROUT SEAL PUMPED:❑ es ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —❑INJECTION U.e.AirSparge.Ozone l❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING❑Nc ❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO-BE PERFORMED: DES RUCTION METHOD:ICHECK ALL THAT APPLY <br /> __3_#OF WELL(S)TO BE DESTROYED _ ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs:. _.l'1 hc/— ] M W W_C fR PRESSURE GROUT TO DEPTH OF__ _3 FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ` LJEXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE PIPE MUSHROOM CAP AT L3 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 re pared this application and that the work will be done i accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and pplicable a ialaws. 5'7AFF (5T / <br /> Signed Title/Company 1V� — - t`+`!D ASSo �iT_c-_[C[iAA� <br /> Print Name SELE412 V.JFAO Date—L91 2�0 11 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS I E + 1J1! <br /> WORK PLAN DATED Q/ <br /> APPLICATION ACCEPTED BY -±2" DATE ISSUED / -13 -// AREAS <br /> GROUT INSPECTION BY P Q (rj iFINAL INSPECTION BY VjtvfrlllqMtZ40 DATE - <br /> DESTRUCTION INSPECTION BY ` DATE 6 •' <br /> COMMENTSICONDITIONS: ` ro U rn <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# lRECV'D BY DATE SERVICERO# INVOICE <br /> REQUEST PR# <br /> 11 <br /> 3502 -3$122x `' 00 1 SR# 00G2?5 <br /> 35030d � 841S3 Roo G4Z <br /> PR# <br /> Z90a <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORI7ATI N TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD,29.01 07/28110 <br /> WELL PERMIT APP <br />