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• • �,y <br /> "gDln SAN .IOAQUIN COUNTY COPY <br /> 2' ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> N` 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sioov.or-qlehd UNIT IV <br /> 4ii F'o'A � <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 1501 D A!q f li Cross Street 5� 4 u4, d (ZCt Citylstate LATA4­�P Zip '1,5330 APN l4 R- 13-03-1 <br /> Propertyn.�-��, �p� 66 Weir <br /> R�jJL <br /> Owner tkk A CAc Pa44s LP Address 4/1" NE�1Pntr/�/dlE�City/StatetJc'�7od-T zip 431 '40 phone 4k4-X11 -7010 <br /> C-57 ContractorVA>u�,;a; TLu1. Address ?,0 • I3ot "74( City/State IL'COJu16.1 Lic 81 414'C' Phone 534�-a tq- acct I <br /> Consultant/Sub Cntr57*1J"fC Address310 U. WN( j5T 410 !P-iLtCity/State 010-Ge,Lic Phone 145-gob QIaq <br /> Billable Party Address City/State Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ®SOIL BORING IDs n jyT¢Z�� <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ENVIIP�OpgEN�MTENTAL HEALTH—E]_ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE&15' 0 MULTIPLE CASINGS [I MULTI-LEVEL WELE'O�t BVICES <br /> 4 <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS yl; TYPE OF CASING: 11 STEEL Q PVC C OTHER Q <br /> O <br /> _❑SOIL VAPOR PROBE El MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE Cl PIPE <br /> _0 SOIL BORING It PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ®No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION(I.e Ar soa a.ozonel❑HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHERTN(Gt P Pff7ai'IE1ZYZTHER: APPROX.BORING DEPTH ZS( ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No[IYes:Casing Dia: Casing Depth: Boring Dla: �1 <br /> COMMENTS: �.S <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 �r <br /> WELL IDs: ❑PRESSURE GROUT To DEPTH OF FT BELOW SURFACE 0 <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 /> 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. L !,- <br /> Signed —T1/ Title/Company ��(ll"✓� - �n�t't�(Jc7- T(,Z,.EIR�DLUC LC-S <br /> Print Name I U )II t6�, 12A,ar(�t,� Date /WZJ)� <br /> _ DEPARTMENT USE ONL ��- <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 156 t 5'ApL; pKW <br /> WORK PLAN DATED -24t 3 <br /> APPLICATION ACCEPTED BY j"is ICU wl. DATE II EA-Liff <br /> GROUT INSPECTION BY FINAL INSPECTION BY Ild—,Pau DATE /-17-1 <br /> DESTRUCTION INSPECTION BY DATE I 'T <br /> COMM ENTSICONDITI ON S: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> '/ REQUEST/ PR# <br /> Cb.l d $125. 3-I r�r -( SR# 46 3 7pD <br /> ip pQ ` RO# <br /> /s I 3500 <br /> 25a� (G34 <br /> C-57 WC v WAIVER A14= C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _/G ENCROACHMENT DOC r <br /> EHD 29-01 5/09/12 / WELL PERMIT APP <br />