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i <br /> y u'^!..�o - SAN JOAQUIN COUNTY <br /> ENONMENTAL HEALTH DEPARTIINT LOP <br /> SITE MITIGATION <br /> :. �. -600 East Main Street,';Stockton, CA 95202-3029 UNIT IV <br /> c�•..__ ..w . Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.smciov.org/ehd <br /> RCIFOR� <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 /> 1210 East Hammer La Kathleen Lane Stockton Zi 95210 APN 0 94-03 0 z-12 <br /> Site Location dross Street City P <br /> Propert hadrall Hammer Lane LP Address 50 Tice Blvd. cityWoodcliff Lake zip 07675 (323)938-0969 <br /> Owner Phone <br /> C-57Contractor All Well Abandonm�ress9245 Beatty Dr.. Ste A City Sacramento LicC-57-848355)hone (916)363-9355 <br /> ConsultanVSubCntrHarizon Environmentalddres54970 Windplay Drive #5 CityEl Dorado HillsLic Phone (916) 939-2170 <br /> Ultramar Inc .Address685 W. Third Street- CityHanford Zip 93230 559 583-3231 <br /> Billable Party Phone <br /> GIS Coordinates:X Y <br />'4 CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> i ❑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 /> I _❑EXTRACTION:Vapor/Water ❑HAMMERIDRNEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:,'D AUGERS ❑HOSE ❑PIPE <br /> ❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:©Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(Le.Air Sparge.Ozone!❑HAND AUGER GROUT SPECIFICATIONS <br /> i _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: i <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> r DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DEST EDM­1- -2;VW-3;VW-4; VW-5; VW-6 Tg OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs -7;Uw-$;SW-1 -3 INW- MW-5;MW- -7; [ PRESSURE GROUT TODEPTH oFq, FT BELOW SURFACE <br /> GROUT SPECIFICATIONS - ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> F TREMIE TYPE TO BE USED: ❑AUGERS `�HOSE LFPIPE C9 MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> a 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 4 " <br /> I hereby certify thI have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and I applicable California Laws. p <br /> Signed p� I����,.�� Title/Company[ <br /> Print Name 1l� 4�s a- -�13..�•- Date of11:FI r-3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS /O - <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTEBY DATE ISS A <br /> GROUT INSPECTION BY FINAL INSPECTION BY LUA E a-1-I <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTSICON DITIONS: fr <br /> ACCOUNTING ONLY: AID# FAC# <br />' PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> I REQUEST !'PR# <br /> 3_6-o3 37!3:- 3,5. 00 a090.� R o0 7 <br /> PR# ' r <br /> {2900) <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />