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o°QuIN c SAN JOP'9QUIN COUNTY <br /> ENVIRONMENTAL HEALTH ®EPARTM T LOP <br /> SITE MITIGATION <br /> d I _ 600 East Main Street; Stockton, CA 95202-3029 UNIT IV <br /> Telephone: (209) 468-3454 Fax: (209)465-3433 Web: www.s' a.v.olr /ohd <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 /> compliance is made in with San <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the wort(described. This a pp <br /> i Joaquin County Develo ment Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> L —east Hammer La Kathleen Lane Stockton Zi95210 <br /> gp ': .094'-X30.=13 =f <br /> Site Location 'ross Street City P <br /> Property <br /> Owner 8hadrall Hammer Lane LP Address 50 Tice Blvd. Citywoodclift Lake Zip 07675 Phone {323}938-0969 <br /> C-67 Contractor All Well Abandonmge�res59245 Beatty .Dr. Ste A City Sacramento LicC-57-84835tbhone (916)363-9355 <br /> Horizon Environment a Dorado Iii11a t916) 939-2170 <br /> Consultant/Sub Cntr Address4970 Winalay Drive #5 CityE1 DoraLic Phone <br /> 93230 559 583-3231 <br /> Billable Pat Ultramar' Inc.Addre5568S. W. Third Street CityHprd Zip Phone <br /> GIS Coordinates:X Y <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 WELL/BORING INSTALLATION TYPE C N TRUCTION SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE { ❑MULTIPLE CASINGS CI MULTI-LEVEL WELL CASING DIA: <br /> v❑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: []AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING t ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL.DEPTH IS 30 FT) <br /> _,•_,❑INJECTION(i a.Air Sparge,Ozane)C1 HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX'OR ©STOVE PIPE <br /> CONDUCTOR CASING I3 No Q Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORT(TO BE PERFORMED: DESTRUCTION METHOD: cyEc ALLTHATAPPL <br /> #OF WELL(S)TO BE DESTROYED O ®OVER-BORE DIAMETER of INCHES TO DEPTH OF ._OFT <br /> WELL IDs: lie ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERS [3 HOSE ❑PIPE [:1 .MUSHROOM CAP AT L>3 FT) .FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby certify thatA have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and al pplicable California Laws. r <br /> Signed Title/Company <br /> y r �t2i7,ot� w�-w� tats. <br /> — <br /> Print Name Imo_ �� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS �`�/0 ������r lam?• � �� ��. - <br /> WORK PLAN DATED AREA <br /> O ACCEPTED B DATE ISSUED <br /> APPLICATION <br /> II� <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> I DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D 13Y DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> I'i D <br /> $125, z1?--5-00 Ro# <br />[ �,� .��.J J�.J• C?O a� ��.5� I3500)�CX�`: <br /> PR# <br /> i {2900) <br /> C-57 WC WAIVER / C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />