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"' c SAN JOAQUIN COUNTY Q R f G ! N A L <br /> �.• �y•.o <br /> y ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> N SITE MITIGATION <br /> •' '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.s' ov.or /e <br /> �/FOR <br /> hn <br /> WELL & BORING PERMIT APPLICATION VE® <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATYAIR 2 7 2014 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED fi�nn,,..,,,,, <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application iar womp Mwith San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Departr mrr <br /> Site Location l4 t)9­4 �! Is 1,4 mess Street ( CAL(/,r.M•� (� City/State C t"- Zip H SZ„6 APN Z <br /> Propertyp / 0& <br /> Owner 1 C 4 E Address City/State Zip Phone <br /> C-57 Contractor hent-C-rt- Address 7_2o g zo- City/State(d,-41.4 6A Lic 90611 Phone 53 -O' G <br /> Consultant/Sub Cntr ERte-We-s1 Address 173-F T rr�l- G3 ­( . City/State"bl 64 Lic Phone `l ZS•-146-- o`/SS' <br /> Billable Party L P M-W est Address 1-L 1 - -Cr,-, E RIS ( City/State LJ,1,1.1 Zip X11591- Phone I/LS-i'Yo-�ys� <br /> GIS Coordinates:X37,jj8j l'_ Y -12 I . y Po 0I 9 Crc._k,(A <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ® NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> 2 SOIL BORING IDs 5 G-1 -r V-1 <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE rr ❑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 /> Lam®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: err k PV,9,) 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 /> #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,and II applicable California laws. <br /> Signed� Title/Company ASsvctu+e ��•yisf <br /> Print Name S T O P H&�N r e&O N C- Date 1- (zy / 1 L1 <br /> c� DEPARTMENT USE <br /> � -ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS j C�I a f er",nR ") /CL�4h - <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DAT - AREA 4 C1 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> c� REQUEST PR# <br /> Iv $ 125 x r (� / 7 / o ec'GtZ• 7 SR# y� <br /> C RO# <br /> 2�co 1 5 3500 <br /> PR# <br /> (2900 <br /> C-57 V" WC t/ WAIVER_4_ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT �'r ENCROACHMENT DOC /�V <br /> FHn?9-01 5/09/1? WFI I PFRMIT APP <br />