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a I SAN JOAQUIN COUNTY <br /> ' ENVIRONMENTAL HEALTH DEPARTMENT Lop <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> Telephone:(208)468-3454 Fax:(209)468-3433 Web:wwor alaov,orufebd <br /> 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 endlor Install the work described. ThIs application Is made in compliance with Sen <br /> Joaquin County Development Title,Chapter 9.1115.3,and the Standards of the San Joaquin County Environmental Health DepaNnent. <br /> Site Location INot-(N %1. w1 521 Cross Street E KaaF1e.•Aa.K L_�_ cityL.:-": Zip41152440 APN o&3-160-25 <br /> property 1 <br /> Owner SwnalSr ')yeti d UyL.+aCI Address \401'1 l 4\w� City�o�. Zip 2 0 Phone <br /> C-57Coneactor Ihd,eonl�c�lls6x- dress3G(7 Twrn �A-lws•s `D7. City APA UD `1 70 Phone 831-66Z-617 <br /> ConsultarnlBub Cntr 'SVC- _ Address 4a5 Rcverxid-c -*-2l City PA%o Uo ISLI14ar Phonel��-y�52- <br /> Billable Party SOC _ Address 4133 kta+ePso;J. A' 24 City Paiso 'kE- CS Zip-ATA! 6 Phond%! 5 "apt-'1 2- <br /> GIS CoordlnatN:X". %4Q3 `4 Y X21_C-r � <br /> C STRU PION WORK LO BEP RIFORMED: <br /> EffNEWWF1'(00RING(CPTROB HYDROPUNCH,HANG-AUGER,OTHER <br /> SOIL BORING iDs_(yr 7—y P2 G+ G.P'i Y' L <br /> ❑WELL IDa <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING IN3TALJ.ATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING OHOLLOWSTEM DIAOFBOREHOLE 2— O-MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DUI• <br /> _p EXTRACTION:Yapmr Wafer ❑HAMIdERIDRIVEN CASING THICKNESS IMA TYPE OF CASING: ❑STEEL ❑FVC ❑ OTHER <br /> _0 SOIL VAPOR PROBE ❑JMUD ROTARY DEPTH OF GROUT SEAL��TREMIE TYPE TO BE USED: D AUGERS 0 HOSE C3 PIPE <br /> _SOIL BORING L7 FUSH POINT(GP/CPT) GROUT SEAL PUMPED:O Yes 5!(No(MAXIMUM FREE FALL DEPT <br /> _E3 INJECTION Oe Arseema onne)❑HAND ANGER GROUT SPECIFICATIONS Ae6k- Ccs .d-Ir- <br /> -0 OTHER: _ ❑OTHER: APPROX BORING DEPTH -!S' O BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING CJ No O Yea Casing Dia: Casing Depth:_ Barg Die: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:rcHECK ALL THAT APPLYf <br /> #OFWELL(S)TOSE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPT OF Fr <br /> WELLIDs: ❑PRESSURE.GROUT To DEPT OF -Fr 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 /> OOMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I herebycerdfy that 1 have prepared this application and that the work will be alone In a=rdence with San Joaquin County Ordinances,Rules and <br /> Regulations,on¢all applka le C� allfomla Laws. y <br /> Signed11A..A-1 w 1r6'�•-itQ•2111L.. TitelCompany n(toaee.-k-"/�teJtnda� 'SG7� <br /> Print Na p�1�4nDate <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSMONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REgUEST PR: <br /> S 125X SR# <br /> RO# <br /> 350D <br /> PR# <br /> a90o <br /> C-57 WC __WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />