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/ COPY <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> . �q..:;;; .�;;P • Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:www.sigov.org/ehd 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. 073 <br /> Site Location 7505 N,t,.iw,yo Cross Street _1L Ju>'I✓ :,1 1`c: City Zip`1 ''D AP 162-01o3 <br /> Property�7 �j pp <br /> Owner P,4-i-Cdfs4yic`Tc, I'Ae—iev Address City Zip Phone <br /> C-57 Contractor �1 villi6,Ci Address �tSU aoLI' PJ City (�'1c+� ��Z Lic ¢?5�1�7 Phone =1,'S 3�3`)??Cb <br /> Consultant/Sub CntrC,v�u,: I G Address III-?, <br /> Zai City 1'4,he�_Lic Phone 2L-,3- 11-:?22_ <br /> Billable Party C�yJ-- .4r& 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(Le.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 /> =3,1 #OF WELL(S)TO BE DESTROYEDOVER-BORE DIAMETER OF 5 +4,iz INCHES TO DEPTH OF ZS-SD FT <br /> WELL IDs: MW 14 1 ct G P 1 'z S iP 10I I, ( PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFITC,`ATIONS ❑ 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 /> 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. <br /> Signed C7'`�`�� Title/Company <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS 3 S OS-- N/4U!� DQ(UC S7—UC <br /> WORK PLAN DATED M p9RC 6 30 2 0/2 Q <br /> APPLICATION ACCEPTED BY _S- !-10 l9 DATE ISSUED I–/Le3- /3 AREA 16 <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 /> �jgyp <br /> REQUEST PR# <br /> O $ 125 x //�� Q7 / CnoZ� LUCt I �17 <br /> Z SR# 076 <br /> RO# <br /> 3500 <br /> PR# <br /> 2900) <br /> C-57 t� WCL�i C57 LETTER OF AUTHORIZATION TO SIGN PERMIT l,— ENCROACHMENT DOC__ <br />