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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENJ LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> \` ;•.. - �;: ' Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.orgleh UNIT IV <br /> /FOR% <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 219 116 Af Ca1w¢fo-4 Cross Street City/State o1n Zip APN <br /> Property <br /> Owner C�1�'fo►K (_4N�tQlp� Address S4VIAA City/State Zip Phone <br /> C-57 Contractor �anQcnoro- 0r�l(„�, Address 240 Nof-K S4, City/Statew0p0("J,CA+ic 0 9?q Phone S;-30 6G !-�b0o <br /> Consultant/Sub Cntr Address 7121 /U G , ,,,,i .<�a Liu City/State00-Lic Phone <br /> Billable Party f Address City/State Zip Phone <br /> GIS Coordinates:X - )2�•'f31� Y 253 <br /> CONSTRUCTIOK WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER.OTHER) <br /> ESOIL BORING IDs rov P-$ <br /> WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ?•�S 1 ❑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.Air Soarae.Ozone)El & <br /> HAND AUGER GROUT SPECIFICATIONS P���r.r j ^,,--F <br /> OTHER: ❑OTHER: APPROX.BORING DEPTH 2 O ',t'- ❑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 Y <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 ElHOSE [-IPIPE [jMUSHROOM CAP AT( 13 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I h repared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,an app/• ble California laws. <br /> Signed Title/CompanyY,,n e.Co., I IU <br /> Print Name VJ L.0% Date (\�-2-1-� 1-1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS z!J -� ✓�% T #`/,77/'7 <br /> WORK PLAN DATED z b1111 <br /> APPLICATION ACCEPTEDZLY DATE ISQ0 REA <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 I RO# INVOICE <br /> REQUEST PR# <br /> $ 130x t hll' A li` SR#dam 6glS-1 <br /> 3 00 <br /> PR# 7�ti�ll, <br /> (2900)t'-2 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> FHD?R-n1 7/24/14 WFI I PFRMIT APP <br />