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T <br /> OP4p.IH SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.oraleh <br /> L%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 voth San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> "if" <br /> v g4rT-occ-wir'VvN✓ ni <br /> ao-01- <br /> City/State ( ^ Zip 5s7 APN — <br /> SiteLocaton H-dl PtFi16 A , CrossStreet Mft"kF , wr <br /> Propert <br /> Ownery//,�� OF StW-V- 0 Address 3°tS 14- 8.Qd(WO City/State it' ZipaskY Phone7n9-" 71liri <br /> fo� <br /> � <br /> C-57Contractor r/Af1.pt,*L I,>Ve Address IG61 City/State 9-tC tCIA- <br /> 49 Lic `L0b"116 Phone 00-236 <br /> Consultant/Sub Cntr ST)",WIVVZ Address JMr-W5 gt-�Q City/State WS (SYS Lic I Phone kGCPA <br /> (t-3S b-6/Z7 <br /> Billable Party C.L6*1" yly' Address bIDI 00t,14W&/ *-6Av-fUW Y4J' City/State ip _Phone D <br /> GIS Coordinates:X037—M2- 10 Y -t 2 1 , 3128 Z. <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING 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 /> _[I SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i a tit Soame 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 /> Timm& <br /> S)TO 8E DESTROYEDOREDIAMETEROF INCHES TO DEPTH OF^-'t'-S FT <br /> W/-'1 �M M/'t S. Yl'1 W'"1 �IPICATIONS �Or ❑TO BE US D:❑AUGERS ❑HOSE ❑PIPE ❑h(k'll � [hbL�:1S ICna{-.�,ct. 'v� RD'R- (-i .f-�W L7 �-�rRKING DAYS•NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 1 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 � Title/Company PW15r�$(/eZtRttS1— 4 Z Lrm'S.$IZVlS. NL <br /> Print Name 6r MJ Date <br /> u•� DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS "7/d7 6 <br /> WORK PLAN DATED " rI <br /> APPLICATION ACCEPTED BY J tt 0 f3Ku wt DATE ISSUED �-7'1 S AREA 16 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COM M ENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# <br /> PE CODES , FEE INFO AMT REMITTED CHECK# RECCV'D BY DATE REQUEST PR# INVOICE <br /> .J[[O 2 $ 1301 772- CO(CIl SR# <br /> Roo) S <br /> PR# <br /> (2900 <br /> C-57 !✓ WC ✓ WAIVER PV C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> WELL PERMIT APP <br /> EHD 29-01 7/24/14 <br /> d�v1& <br />