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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> N111�) <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> UNIT IV <br /> �;•-� Telephone:(209)468-3147 Fax:(209)468-3433 Web:vwvw.siclov.orcl/ehd <br /> 9ciFod; <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 40t, L3 Cross Street P—tc City/State (46/,�} Zip �1s33a APN �1- Zl- A2� <br /> Property <br /> Owner��e� Address 3'10 rnwna Grm6c %,. City/Slate ��Zip 7 S3 ao Phone 7.05--14 1-�za0 <br /> C-57 Contractor QjLJ D nib„ _ Address 360(o h-,I- [_reek. t, City/State_A!,A 4Lic Phone zoy- kb5 <br /> ConsuitanUSub CntrtqG►za E,,,_ Address .5Sr0 A.c.1a...a A 61-A City/State ,?n./�Lic ✓1 4A Phone 7.61. 49-t (b <br /> Billable Party Elgaeb !'C, Address City/Slate Zip Phone <br /> GIS Coordinates:X 71��3 Y —121. 3C4 L.F lo.r <br /> .fZGOt& -- I Z1, Zo_od-1 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/ORIVEN 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.Nr sparge.ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dla: 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 W ELLS)TO BE DESTROYED ®OVER-BORE DIAMETER OF NCHEs To DEPTH CF__L)-_FT <br /> WELL IDs: W ❑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 Q9 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 al cable California laws. <br /> Signed Title/Company��., ✓” 4c ,. ci l�N C IZPJ . <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED M'� 9 C)/ ,-1 <br /> APPLICATION ACCEPTED BY J 01/?Ku v�I DAT - AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY J. DATE <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 /> IU $125x Jf. (X> ZU�fU CLC- SR# <br /> RO# <br /> 9 U 3500 <br /> PR# <br /> 2900 <br /> C-57 v WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOCN(1 <br /> EHD 29.01 5109/12 WELL PERMIT APP <br />