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SAN JOAQUIN COUNTY I ./ r <br /> ` ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> .. --. ;a Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:wwwsioov.ora/ehd UNIT IV <br /> FORS <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 IOSO,SJ '01AMOM O Cross Street CI•kAR't'':lt WO,)' City STOCKTDAI zip 9SZ-0S APN /SS- 32. 4014 <br /> Property r <br /> Owner PiAYldAtD r0005 AddresslOSO 'T 'U/AMOAID CRy TW—k-116tl zip 9SZOS Phone207.4(97_i6000 <br /> C-57 Contractor Address City Lic Phone <br /> ConsultantlSub Cntr Ajj "bC/A`?Uddress 111.7 LONIP "t;)4LM AVE. City MODG-STO Lic? S(p0({ Phone20`7-579-2221 <br /> Billable Party AI-TC--A_20CIA'rEFS Address 1117 WdF- 'hALM AVt• City MO•DESrO Zip'}53S1 Phone -574-2.221 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> yr❑SOIL BORING IDs <br /> WELLIDsLJ <br /> OTHER IDS REP ENT WELr.- '766X&&. F02 t1f M� W-7—� .11 <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _O EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE ❑PIPE <br /> _0 SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION(i a Ar Soaroe.Ozonet 0 HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: 0 OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR []STOVEPIPE <br /> CONDUCTOR CASING 0 No 0 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 APPLYI <br /> _#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑ DEPTH PRESSURE GROUT ro DEPOF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS El EXPLOSIVES FROM TO FT BELOW SURFACE <br /> COMMENTS <br /> TREMIE TYPE TO BE USED:❑AUGERS [I HOSE ❑ PIPE ElMUSHROOM CAP AT(>3 FT) Fr BELOW SURFACE <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,//annd�d all app]]Qable California Laws. <br /> Signed TRie/Company ISR-OTECT MANA6E72/ LTC ASSOCIATE=S <br /> Print Name bEAMJE-_ 400tisey Date (0- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS 1nt�� l4ft10A1_b 157r,66-r <br /> WORK PLAN DATED ' <br /> APPLICATION ACCEPTED BY J -`fo 14KU tM DATE I� EA /(og <br /> GROUT INSPECTION BY FINAL INSPECTION BY �/ & OLE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: G 2 <br /> 25 /i. stern 2G I <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AT REMITTED CHECK# RECV'D BY DATE ERVICE RO <br /> M # INVOICE <br /> REQUEST PR# <br /> $125X ! r25 (22o erg SR# 4So 3 <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57_ WC WAIVER V C57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOC <br />