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41ECE'VRA L <br /> SAN JOAQUIN COUNTY <br /> N — ENVIRONMENTAL HEALTH DEPARTMENT MAR 2 8 24 LOP <br /> ll SITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6 IRONMENTAL HEALTWIT IV <br /> • c ��F° $ P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siscaMMVI <br /> 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 ICI (�IYNU�JI Cross Street thkri1SlgUy yr City/State Jt Zip IJ& APN <br /> Property^ ,( s7� <br /> Owner 1�1I /^1 Address 0p � Cu City/State ! i►wkipgs$Z 33 Phone GZOy qO-O7lJfrJ <br /> C-57 Contractor Address y /1K k City/State�a Lic` 93�I Phone_1 6 0 / 35 <br /> Consultant/Sub Cn 5 V Address 3332 NK�Q/r 0557 City/State(Lic Phone S50-f`o 7S� ?,iz <br /> Billable Party 61(/I1AiWt&&W Address 3n(4WW MPK Dr,-0:52 City/State G~—Zip 6$ Phone 551-� 7�z 62F&,;> <br /> GIS Coordinates:X 37, Y -121.17615- <br /> CONSTRUCTION <br /> 27$15-CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORINQjDs <br /> WELL IDs !37'� _. I .A. fhpk,,N IA ji � Aw <br /> OTHER IDs <br /> TYPE&#OF WELLJBORING INSTALLATION TYPE CONSTRUCTIONSPECIFICATIONS <br /> _❑MONITORING HOLLOW STEM DIA.OF BOREHOLE �C ❑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 33-31 TREMIE TYPE TO BE USED: AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:tYe�s/'C}No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> INJECTION(i.e.Air Soaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Q <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH1 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 /> #OF WELLS)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 /> Regulati nss,a d all applicable California laws. C <br /> Signedl Title/Company J'{1/Z ►v,'�n <br /> Print Name 5w4 GA-ui Date-L-1 -� <br /> / /DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE I SU AWAWREA �G �/ <br /> GROUT INSPECTION BY FINAL INSPECTION BY GMI k ovi DATE ' 46-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 I PR# <br /> aq0 $125X(I SR# <br /> asO � 3� RO# <br /> (3500 <br /> PR# <br /> (2900) <br /> C-57 WC 1✓ WAIVER r C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC_,Q,61 <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />