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SAN JOAQUIN COUNTY <br /> �`r ? ENVIRONMENTAL HEALTH DEPARTMENT i. LOP <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:vvvv.siclov.ora/ehd UNIT IV <br /> w <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 Dgv I y�9_t(�title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. /&Zp'30--07 <br /> Site Location57V?��i T1 Jv�>,� Cross Street cv•'dt -, -e City Zi f.03 APN 1 62 0 <br /> Property <br /> Owner �� Address 0.2.01 w2:1(�,��;y� j4 City ��, �[<-A Zip•152. 3 Phone 2G")''1f-6--C-Z-f <br /> C-57 Contractor v ? ��/1(1-' Address ?;30 4-jc u, City Z- Lie 43516-5 Phone`12 S-;13`5'eoo <br /> Consultant/Sub CntrCr v�IHo ATC- Address I II-- ,rl�ti� 4' r$, 1 City Lie Phone 7,<?-%­jL'3-22?f <br /> �+ <br /> Billable Party ( -J4 k'I�i 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 Sparge.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 /> _Q#OF WELL(S)TO BE DESTROYED jaOVER-BORE DIAMETER OF kt,112 INCHES TO DEPTH OF •.,V viZ, FT <br /> WELL IDs: 16�t ZLT 2t o _Z c i .117—IS )6 17 , M(. 1 y ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS tE ' ❑ 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 �,,.(?V 4 ;,a A, ,��r .,r-�; ��1 � �1� ,�;��1• � w �l - - <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 applicable California Laws. / A/j <br /> Signed �/_ — Title/Company S4 •t'T(�) ls-eJ,i;-J / C,'I"v —, <br /> Print Name r , .✓v���rr� Date y-13-15 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS S o S IU V)-V�� 5 Tb�?W 7-Qe& <br /> WORK PLAN DATED 1•J R C�!� 3 C'_ e-1 C, / Z- <br /> APPLICATION ACCEPTED BY X14<k t DATE ISSUED ?-18 AREA 9 <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 /> G y REQUEST PR# <br /> (d 2 $125. l0 1 250 I �4 0 2 CU°tt PTE -1 7- SR# 6,9 072 <br /> 3�5 3�5 3 00 <br /> PR# <br /> (2900 <br /> C-57 WC r/ WAIVER ► C57 LETTER OF AUTHORIZATION TO SIGN PERMIT_ L/ENCROACHMENT DOC_PV4 <br />