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ofRu'N SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTM NT LOP <br /> W: i <br /> fff 600 East Main Street, Stockton, CA 95202-3029 ��lJ]V I <br /> ' CSR.•._.:-��P Telephone: (209) 468-3454 Fax: {209) 468-3433 Web:www.s' ov.orlehd <br /> CIFOR i .. <br /> WELL & BORING PERMIT APPLICATION JAN IS 2013 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIP.ONMENTALHEALTH <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 comprianlCc WPtSS <br /> Joaquin Counje a ment Title,Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Locatiorl�L• East Hammer Lar&oss Street Kathleen LaneCity Stockton. Zip 95210 APN'`0 94-03 0-l l <br /> Proper%hadrall Hammer Lane LP 50 Tice Blvd. 'Woodcliff Lake 07675 (323)938-0969 <br /> Owner Address City Zip Phone <br /> All Well Abandonm�ress9245 Beatty Dr.' Ste A Cit'Sacramerito LicC-57-848351bhone (916)363-9355 <br /> C-57 Contractor Y <br /> l Dorado Hills (916) 939-2170 <br /> ConsultantlSub Cntr Horizon Environmenta kddress4970 Windplay Drive #5 CityE Lic Phone <br /> Ultramar Inc . 585 W. Third Street anford 93230 559 583-3231 <br /> Billable Party Address Wt CityH Zip Phone <br /> GIS Coordinates:X Y <br /> S 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 ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED: I]Yes .❑No(MAXIMUM FREE,FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.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 THATAPPL <br /> #OF WELLj <br /> S)TO BE DESTROYED Mw-9 ❑ OVER-BORE DIAMETER OF CHES TO DEPTH OF FT <br /> WELL IDs: [a PRESSURE GROUT TO DEPTH OF (U� FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES.FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: ❑AUGERS [R HOSE ❑PIPE Ia 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 allrApplicable California Laws. i <br /> r i ` <br /> Signed 4t. title/Company )■va �+ uatJZiNOO <br /> Print Name Date b t [ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS %O <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED DATE IS EA <br /> GROUT INSPECTION BY FINAL INSPECTION BY .BATE <br /> DESTRUCTION INSPECTION BY DATE v <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D:BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> -5-0.R $125x 05707 S R# �_C <br /> RO# <br /> E: 0 3 a 0�b7 d/ (3504)OOGL'7L') Q <br /> PR# <br /> 2904). <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> i <br />