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A ' <br /> ,at'4"ty..co SAN JOAQUIN COUNTY CRIGIN <br /> y <br /> .Z ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> Telephone:(209)468-3147 Fax: (209) 468-3433 Web:www.s*gov.org/eh <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 Ud .t'rluViS t C� j w-',i Cross Street City/State LG, i�(: Zip APN c I/9 1 So- r� <br /> Property <br /> Owner /Ve,i Address 1L. To(iiiStriz:l Wt'•Y City/State ,PLS (,CSF Zip ` S)Ilo Phone 00,; <br /> C-57Contractor A/p,Lf1 4rrQl'r_4;1 Address rlo,�- TOAitsi r)"I toC+� City/State -1•JI ra Lic ` Phone (.1 •')3C f _3 1t.J <br /> Consultant/Sub Cntr Address City/State Lic Phone <br /> Billable Party�w Ic�_Rri(i,rY.'i Address `/G,- 1"nj kJi-r 91 Wc:V City/State tc.11 r' Zip 1 c Phone <br /> GIS Coordinates:X 37, 9y4i Y ^1 2 I '265 2- <br /> CONSTRUCTION <br /> 652- <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,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 /> _❑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 AirSoarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX,BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑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 /> _I_#OF WELL(S)TO BE DESTROYED SOVER-BORE DIAMETER OF _INCHES TO DEPTH OF 7 ,� FT <br /> WELL IDs: A/ j2�PRESSURE GROUT TO DEPTH OF G FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ��. +li•n f e�.Y1Prl t- ryr'k, I, _ PLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE 5d PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS W.IN ).loll I^t }zt ) ! +'Cjl S(14/+nd�QfLilrliw fr i/T1TSt,m< <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify It Ver <br /> prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, all pl le C ifornia laws. <br /> Signed Title/Company I2� /V611— O. . <br /> Print Name �' `t✓'/ Date VJ­11 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS Z Z �Nw7- %G. W—MA z' L//l)/ 1` <br /> WORK PLAN DATED )4Vi' I M S 6 <br /> APPLICATION ACCEPTED BY�, �X 0111L DATE IrMICIMMIMPLIMEA 1/ <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE I <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> / REQUEST PR# <br /> $125x 7 -4 Z5o\ �� /Lt%//y SR# 49' 3G1Q <br /> / <br /> Z�I 6 Zi 7 1 7,75 RO# <br /> 3500 <br /> b2y iso 053 7 3 <br /> C-57 V WC WAIVER N C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT NA' ENCROACHMENT DOCS <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />