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ORIGINAL <br /> e <br /> u'n SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> •' 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> *�IFOR�i 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 Department. <br /> Site Location lZ(o} (SV*," C{lh 13WCross Street N- PQA <br /> T-Sht!i ,,tQ. City/State +UC, Zip I)YO'f APN (I .Z -17- <br /> Property t� <br /> Owner escouto Y'I &tAfj Address 1(0(2 yvLr lc t AVO- SrC <br /> J it City/State ,,,,�,,,,�Z�ip� 5�9 Phone <br /> C-57 Contractor ascad2 �ri ItfVtct Address 0 �tn,�.11L. S+. City/State`V" G�� LLic ll O Phone [a t�) KJ3 <br /> Consultant/Sub Cntr /� Address !U�(�°l T �9M City/State �� is b�5 3�G Phone tr�l 16) �0t-gam[LS <br /> Billable Party C (YbI�G U5 Address " City/State h Zip Phone <br /> GIS Coordinates:X 37• 4( 1gBo Y -/I& 3/yq/ <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 WELUBORING 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 ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.g.Air S rae ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING C1No ElYes:Casing Dia: Casing Depth: Boring Dia: <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 ELLS TO BE DESTROYED VPI, v�2� P—� <br /> �Y ) OVER-BORE DIAMETER of - CJ INCHES TO DEPTH OF T <br /> WELL IDs:J_t -2 S-3 5-+-) 5-� $-8 5-t0,S-lI 5-tZ 5-t3 S-I'i S-lb ❑PRESSURE GROUT TO DEPTH OF FT BELOW S RFACE <br /> GROUT SPECIFICATIONS I ! ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: -AUERS ❑❑ E PIPE GSC 12/ah hQ MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE <br /> COMMENTS I <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify th t have pared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and sl le Calif is laws. ,1 <br /> Signed Title/Company G�T <br /> Print Name I <br /> Date Z Z <br /> DEPARTMENT USE ONLY <br /> / <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS f 2& <br /> WORK PLAN DATED w'(/r{ /l-I <br /> APPLICATION ACCEPTED BY J• y,__ 19� D E SUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE-92� lye <br /> DESTRUCTION INSPECTION BYVX <br /> DATE -,2 J 3 <br /> � U <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 /> 3s�z $130x /fj'0­-)ya Cok SR# <br /> 3So 3Q0 ncr - RO# <br /> (3500) <br /> PR# <br /> 2900) <br /> C-57 ✓ WC WAIVER 0.2& C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC <br /> EHD 29-01 7/24/14 WELL PERMIT APP <br />