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• SAN JOAQUIN COUNTY • ORIGINAL <br /> ENVIRONMENTAL HEALTH DEPARTME T LOP <br /> •.'�° F� 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> Telephone: (209) 468-3454 Fax:(209)468-3433 Web: .s' ov.or lend UNIT IV <br /> '/Ci F bRN\ <br /> WELL & BORING PERMIT APPLICAT ON � I V � <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATION AND T GE <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED '}r�'' <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is 6@W6 irl2co�npll� I With San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 49111 &A w-, vvAK 44 Cross Street 5- /aha City Zip 24i1WAR NMEWRNLTM <br /> Property 'L p�RIe VI <br /> Owner k. 1 /7r� {L jr Address /Orf48 (orp�lPit�pd/.s �� City S�64k,6. Zip SANS one <br /> 2 9 7.37?? <br /> C-57Contractor P.ce nra— Ldozny Address 1365 C./�a,.... �. City 5vg.leyla. Lich36307 Phonee'2o9)Y6S-8713 <br /> Consultant/Sub Cntr&S, rr_. ddress 9NY//�/ Sc✓k f/ City Lie Phone(:,74272--Y26D <br /> Billable Party YJfa <br /> v ..ce j!�.o.* .7nz. Address at Sa.+le!'/ City !/a Zip 95'x/9 Phone Cr;o)271�jyoo <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> 10 WELL IDsS <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 2i.®MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE q ❑MULTIPLE CAS NGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS all TYPE OF CASING: 0 STEEL W PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL "' TREMIE PE TO BE USED: Z AUGERS 0 HOSE 0 PIPE <br /> _O SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes 0 No(MAXIMUN FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION(I a Air Soame.Omnel 0 HAND AUGER GROUT SPECIFICATIONS <br /> _O OTHER: 0 OTHER: APPROX.BORING DEPTH /00 IJ BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING 0 No❑Yes:Casing Die: Casing Depth: Boring Die: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHQD•(CHECK ALL THAT APPLY) <br /> _#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: 0P RESSURE GROUT]]TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS El EXPLOSIVESFROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AAlirr(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR I F SPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with an Joaquin County Ordinances,Rules and <br /> Regulations,and�all a/pplicable California Laws. <br /> Signed <br /> Title/Company S � ,Scrtn4 s <br /> aa'� • � <br /> Print Name Date-/j�2o�o// <br /> q DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESalA <br /> WORK PLAN DATED L <br /> APPLICATION ACCEPTED BY DATEISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTSICON DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DAT REQUEST I # <br /> 01 $125 x Z J V / SR# <br /> '/ RO# �/1? <br /> 6 l J 7 1500 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />