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• • to <br /> SAN JOAQUIN COUNTY C <br /> 2` ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 2A <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.oralehd 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 Department/io Rt 01 LA) <br /> Site Location Cross Street S —74/� Ai City 5;�-ke— Zip 9f2/3' APPN o7//v <br /> Property 5�,,, To <br /> Owner/t S/,� 4/tl Lkw/Mw.� Address /8/O &is LL.,se/1a. /fie City SVecLfu Zip 9jt65 Phone ego? %g-30oo <br /> C-57 Contractor f3acn/� Sn.gaL+4 Address .2361 L/rr/r., an, City Lic 676 3r7 Phone C207)5/65'-MZ <br /> Consultant/Sub Cntr&5..-.. &04J;e. Address 9YY1/&W1;. S'alk-d City Lic Phone C5r10)272-Y2ee <br /> Billable Party Tile Son.se l ,.Lk. Address 99Y A,Co vA/a Rd. Su:ft•f/ City G.nes Lt✓/ems Zip 9S9Y9 Phonee�'3v)272-Yaau <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> Dd NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> 0WELL IDS fl/ -I� ft -3 <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 3 fia MONITORING 19 HOLLOW STEM DIA.OF BOREHOLE D MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _D EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS }� TYPE OF CASING: D STEEL ®PVC D OTHER <br /> _D SOIL VAPOR PROBE D MUD ROTARY DEPTH OF GROUT SEAL 70' TREMIE TYPE TO BE USED:ja AUGERS D HOSE ❑PIPE <br /> _O SOIL BORING D PUSH POINT(GP/CPT) GROUT SEAL PUMPED:D Yes D No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _D INJECTION(I a NrSoaroe.ozone)D HAND AUGER GROUT SPECIFICATIONS <br /> _D OTHER: D OTHER: APPROX.BORING DEPTH /Uy 8 BOLTED TRAFFIC BOX OR D STOVE PIPE <br /> CONDUCTOR CASING D NOD 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:(CHECK ALL THAT APPLY) <br /> _#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES 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 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. <br /> Signed Je--- n Title/Company 5jf. ' 5�.� Y f� T.1t Sai.« G...P .Zirc. <br /> Print Name A-/. 9.0..... Date /L.Zp120# <br /> DEPARTME T USE ONLY 1 <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY / DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: , <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO INVOICE <br /> C' REQUEST PR: <br /> 01 $125, 0 /Y SR# LIZ- <br /> zRo3 s �S a 00 �? 7 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />