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SAN JOAQUIN COUNTY �J <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> y <br /> • 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone:(209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/eh 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 <br /> Department. <br /> Site Location 0 ��Vy�D� Cross Strelet �\1\\\�����Q \`j �Q City/State ip� �c��j APN b�� <br /> Property '\ ( h`\ `U• .7 ' ty <br /> Owner ���' �c�L- Address �1 Ci /Stat��01- <br /> 1 1�Lip 1 J r�Phon I I <br /> C-57 Contractorf�E`+C\yJ'�tL� l 1(� Address I1� 111 C�C N�V 1 1 �� City/State Li �` hon CCS j <br /> ConsultanUS``ub, \C,,ntA—A 'mw,U Address 101 ,�)3)(�\}C` `� V City/StateC Phon <br /> Billable PartyN\\ C�JOn) , �} <br /> �Ad&3 ��� UCc V� City/StateC �Zipphone )- 0 <br /> GIS Coordinates:X1`I C� �a� �IqY <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs _ <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS [3HOSE [IPIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:[IYes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE <br /> CONDUCTOR CASING❑No Q Yes:Casing Dia; <br /> COMMENTS: Casing Depth: Boring Dia: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHFCK ALL THAT APPLY} <br /> #OF ELLS TO E DESTROYED ❑OVER-BORE DIAMETER OF It CHES70 DEPTH OF&SU�R�FAFTE <br /> WELL IDs:�U)-� �.� >� �f�\,, 3 � �1�\�) ❑PRESSURE GROUT T DEPTH OF FT BEL <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM o FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT(>3 Fly / 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 accordance with San Joaquin County Ordinances, Rules and <br /> Regula ions n Ia icabl California laws. (� <br /> Signed \ Title/Company <br /> Print Name \iJ Date S <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESSS <br /> WORK PLAN DATED Zo( <br /> APPLICATION ACCEPTED BY J- `f v�}I��� DATE ISSUED //Z-1 2 AREA /(A, <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> f' <br /> $125, SR# <br /> 2 32 37RO# <br /> J (3500 <br /> PR# <br /> C-57 WC _(WAIVER 41C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ ,/ENCROACHMENT DOC <br /> EHD 29-01 5/09112 <br /> WELL PERMIT APP= <br />