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SAN .JOAQUIN COUNTY RIVE <br /> >.•'tfE'•.OG <br /> ^`r'—` `? ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> < �L JQ,} SITE MITIGATION <br /> • 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> cQ:.•d -.�;P Telephone: (209) 468-3454 Fax: (209) 468-3433 We�-WRWWv.orl�t HF d <br /> /FORTH <br /> WELL & BORING PERMIT APPLICAIVWERVICES <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 1IYo w. Cross Street TL otvv RoCity C.+-r-t-f--\ Zip ysZO`1 APN 6q7 -- yc?0- z-7 <br /> Property kv motes �u ly <br /> Owner Address Po 13ON 1496 City W0.410, 9r;t Zip 4L-, Phone 0-64)3(-7`byy Z <br /> C-57 Contractor Address -�Xv to D­ c-eek D,- City 54,t-h4 Lic cs�-72oyuy Phone (z°9) y b q-7 7cc <br /> Consultant/SubCntr -r' Address l'11H vU:^ 5�,,-e 4- City Lic PV-8g'jIL{ Phone (+U1)Y3fr'-9YYE' <br /> Billable Party 4.u�T�i Address 12 I4 A,":- S+ve e F City S'fu ctt 4T— Zip 15 3 L <br /> Phone (zo9)E;1F-9'Ye,�- <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 /> ❑x WELL IDs 2,-) 1 T vJ2_ <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _E]MONITORING ©HOLLOW STEM DIA.OF BOREHOLE (b" [3 MULTIPLE CASINGS[I MULTI-LEVEL WELL CASING DIA: q" <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS 5ck. 4 J TYPE OF CASING: ❑STEEL IS PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL -7-y TREMIE TYPE TO BE USED: [Z 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 I've c,+ Ce e^+ '110. i' <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH So, 0 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 /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT To DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑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 applicable California laws. <br /> Signed )"e \j°''jTitle/Company SkuFF (rQD)oy,S+ /UrO�rd_ Zero ��•�Ys:S�I�c• <br /> Print Name 30e ag __ Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS f�LI b w• /LoP <br /> WORK PLAN DATED / 7 2,o A <br /> APPLICATION ACCEPT4 BY jt /� DATE ISSUED // 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 /> / REQUEST <br /> G PR# <br /> 3 01 $122xZ ( ;O SR#6 1 3 g <br /> 2 _ RO# <br /> D Jr� ��� t' y I 3500 � <br /> PR# <br /> I 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROA HMENT DOC <br /> EHD 29-01 07/28/10 WELL PERMIT APP <br />