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P SAN JOAQUIN COUNTY <br /> 2 ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> �. <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> q P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.si-ov.org/ehd UNIT IV <br /> �/FpR <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 �� S / Cross Street ,De "t �� City L Zip 150 APN <br /> Property ��, n �' " _ / <br /> Owner �MGI/lA1 Y 16�(e►n AL Address d0`1 Si E1 � sAL City 5 � _ Zip _Phone 26 <br /> C-57 Contractor 1ddress p 1 V1,4 <br /> rt�Cijty Lic�c8�"51jo Phone 7ZS � /(/((� <br /> Consultant/Sub Cntr v Address i' sty Licg5V Z Phone Ci 3D- 76- 2kT <br /> Billable Party ✓, _ AddressCity ( Zip q5 $Z Phone53�-67G-Z <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WE IL BORING <br /> (CPT,GEy�PROB I Af Ute,lIAt�U,�QIGER,OTHER) <br /> SOIL BORING IDs �!'I J'IJP, m(7 <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 /> ❑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.e.Air Sparge,ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR [I STOVE PIPE <br /> Z QON UCTOR CASING E]No C]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(>3 FT) FT BELOW SURFACE <br /> COMMENTS <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, nd a a plicable California Laws. /_- <br /> Signed Title/Company Prp I(d A/ — 5f/44 Nrtyr�0� <br /> Print Name t Date S I—{3 <br /> 11 DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILFISITADDRESS <br /> WORK PLAN DATED �1l <br /> APPLICATION ACCEPTED BY DATE ISS ED J �I �ARTE6A�� <br /> GROUT INSPECTION BYFINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> h ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# <br /> REINVOICE <br /> QUEST PR# <br /> �a05 $125 X SOO.AD a97812-98o /S r SR# 10 I <br /> RO# <br /> 3500 <br /> PR# <br /> (2900 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />