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gJI.N. O <br /> SAN .10AQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> • .. ..;P• <br /> Telephone: 209 468-3454 Fax: 209 468-3433 Web:www.sigov.ora/ehd UNIT IV <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. /&2_03d <br /> Site Location I\L"14 V4Cross Street !-r +v .h 7: ^c) City S-6414ov1 Zip` 5473 APIN <br /> Property <br /> Owner Clay-,( L4tldress ) 1-56K 7'5160"I City h,�ia r14Zip Phone'I"10`3ICS--2c;c' <br /> C-57 Contractor �ri��_ i�,� Address I-6-jz e-1 City /L7-;,4'-irZ LicPhone <br /> Consultant/Sub Cntr GG,J: n ATC Address IIIA-L,,t,,!P-J,Ave City /_1.111`1,1_. Lic Phone. y-;-Sic)-22?I <br /> Billable Party el-,yji,.n 4 T C Address City Zip Phone <br /> GIS Coordinates:X Y <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.Air Soarae.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 /> _tS #OF WELL(S)TO BE DESTROYED 54 OVER-BORE DIAMETER OFY-,r 17— INCHES TO DEPTH OF `/"Fits FT <br /> WELL IDs: t1w-1 K 5 6 3 1 "1 I O 141( P-.5. rP-G. t FP-Z. 2- ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS 'Ne.. ❑ 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 all ppli ble California Laws. i A <br /> Signed Title/Company ST-,-}(�=J Is l oa s"+- AC"'' L'0 /+I c <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS S�S GV 01 V D 2(U E SC'/CtU1 p 6 <br /> M WORK PLAN DATED /,1 ISI R0 f{ O, Z1�( -2, <br /> APPLICATION ACCEPTED BY o og x n� DATE ISSUED 9- /c4-/ AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY 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 /> p REQUEST PR# <br /> X I o 2 $125 x /5- 15 + O z " (4-0 U Ou TQ- —i7-I SR# (� <br /> 19 o 3 3 7� VS- R Oo <br /> PR# <br /> 2900 <br /> C-57 WC 7WAIVER 0057 LETTER OF AUTHORIZATION TO SIGN PERMIT /i ENCROACHMENT DOCS <br />