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y • • FILE COPD <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone:(209) 468-3147 Fax. (209) 468.3433 Web:wWw.sigov.orgteh UNIT IV <br /> 1 FG <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 jo,z 6 . 6:4w{/-i wt EL�Cross Street k M v A!&/,,.0 Dr. City/state Ir�,CA Zip q5-3 i6 APN 25o azo 68 <br /> Property. �7?? � �'C�Z��•• <br /> Owner ?3z;Ae-6r-sL -"e- Addresses/0-+. CIH.fes. City/State'�4l�l—II.C+aipq'159S Phone 9Z5--q15-65.2.5' <br /> C-57 Contractor F8u; core V..-;Iliw; Address=&N.c�a5f St. City/Statei0t4tk1JXA Lie ft0q Phone 5'3,�-60-3600 <br /> Consultant/Sub Cn�tr T4r5ct1� Addressah21City/State�•U`4 Lie Phone 9�5-9-ff-3r-37 <br /> Billable Party -P"Isen5 Address City/State " Zip 9»6-50 Phone <br /> GIS Coordinates:X 37. 7H7(9 Y —IZ I, 41145' <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) y , <br /> E]SOIL BORING IDs /y <br /> ❑WELL IDs <br /> ❑OTHERIDS <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA- <br /> _E]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 0 HOSE ❑PIPE <br /> ❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ❑INJECTION 0 e At,Spam.,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 THATAPPLYI <br /> #OFWELVS)TOBE ESTROYED El OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: b1P-I rw ti PRESS URE GROUT TO DEPTH OF reZ Fr BELOW SURFACE <br /> GROUT SPECIFICATIONS el eew [--)EXPLOSIVES FROM TO Fr BELOW SURFACE <br /> TREMIE TYPE�TO BE USfE�D� :❑AUGERS ❑HOSE ❑PIP 1�1USHV0 M CAP AT L3 ) FT BELOW SURFACE <br /> COMMENTS >�- rt•'R�c-I..cL( D7-SC -a,�r-V' W c� a C 1 iei r' c I P <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 /> Regulati and all apa li rrtta-laws. <br /> plic <br /> Signed .-- F. I� Title/Company <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESSrJ 20 E , fr2ra.t. NC Ro4i) , /RF}Q'f <br /> WORK PLAN DATED IVvva.�t AeR 3r a . <br /> APPLICATION ACCEPTED BY •70;'Zk M DATE IS f('7'? <br /> GROUT INSPECTION BY FINAL INSPECTION <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 I PRO: INVOICE <br /> / -7 p O ,r REQU^E�STTp ry <br /> 2 (D2 s130X (1 / v�CJ��/ &-Y4 A.' I (?-1 SR# <0 ( / <br /> RO# <br /> (3500 <br /> PR# <br /> 2900 <br /> C-57 I/ WC _WAIVER N C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC_ <br /> EHD2M71 7/ 4/14 WELL PERMIT APP <br />