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• INAL <br /> �ot•4����..ctla SAN JOAQUIN COUNTY • ORIGI - �� ' <br /> Z` ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> „. <I <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> �o <br /> P Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.siaov.Orgleh UNIT iy <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 compliancewith San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Heall De anmenl. <br /> II Ave- . sZ0y <br /> Site Location ZID3 li,..,'�n/ CIJL We Cross Street Fal„K� ACity/State Sfoc� M Zip � APN IL3-0$0-29It <br /> Property / / I � ,1 <br /> owner P'la. 4_ t��S�f Address 3S3f G�,+�(i.,-r C7cl�. City/Stale Sibci� tt Zip I520A Phone Z -71-33 ' <br /> C-57Contractor (:,7�/,L yr C- Address ?err SD,>ti PA�.-s (7f- City/State .9 f: Cr! Lic L,4SQ'!U Phone($3r)661-(sl 7B <br /> Consultant/Sub Cntr , Address 2-1 F� S"r City/State 3a Ac m Phone(t z3�S/Z-7f36' <br /> Billable Party �7ii e�"S fi ' Adtlress Sa.�Lo CilylState'b.�i • r1 Zip JW`f0.3 Phone 5e. T <br /> GIS Coordinates:xQ32. Y -12-11 Yz84¢ <br /> C NSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT GEOPROBEJHYDROPUNCH.HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water -❑HAMMER/DRIVEN - CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> -$SOIL BORING PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _[I INJECTION(i. Nr Soewe.Ozonel❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> / f ` C NDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: SL'e- A GLI�GI SLC�1l. J� pL <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 WELLS)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(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 1 hereby certify that I ve PF <br /> pared this applic wn and that the work will be done in accordance with San Joe uin County Ordinances, Rules and <br /> Regulations,and all�,(fpfca(yylee C rma p (' <br /> Signed f .( >iI JiJ <br /> Title/Company Ir'o_ s �l- � <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 4 1(-3 W CfokurRx PAa 3 &1'y0)157WC'71"0 <br /> WORK PLAN DATED APR,L <e . zo IS <br /> APPLICATION ACCEPTED BY 'j.'1e)IIkst1K DATE ISSUED Y-8-/5- <br /> -/) AREA <br /> GROUT INSPECTION BY -Tt-A CAA M 14 w t 2tGl I_jA l,� (2.1Ntp s.P .til DATE <br /> DESTRUCTION INSPECTION BY Sr /tt �MSpe �'' <br /> COMMENTSICO N DI TIONS: <br /> ACCOUNTING ONLY: AID It FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> c REQUEST PR# <br /> 10 $130X O 3 S 7' SR# 719 R(e <br /> RO# <br /> 3500 <br /> PR# <br /> _ (2900) <br /> C-57 �/ _ WC ,/WAIVER A/M_ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT OV ENCROACHMENT OOC <br /> EHD 29-0177124/14 WELL PER I APP <br />