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t r <br /> • • FILE COPY <br /> (� D <br /> SAN JOAQUIN COUNTYENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> Telephone: (209)468-3454 Fax:(209) 468-3433 Web:www.seclov.org/ehd UNIT IV <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 <br /> "Title, <br /> 'Chapter 9-1115.3,and the <br /> nStandards <br /> soof the San Joaquin County Environmental Health Department. i%-0.3a-03 <br /> Site Location !/SOO 00-14' AA'r1 9 r`'Qo°s`s street Kt�Y'✓I ,YOCLoc city L4�Zip 5330 APN L!2� .39-L2 <br /> Owner WWZAII—V57u_ c L� Address �O/�� <br /> nit-><}vt.Sr.•k/3o�cily ,Sam zip 98�Pnone �6 So! qsi9 <br /> C-57 Contractor 61-e4Crfn///1tC� Address 95T lk�W,,eJ-'A''-e- city /Yl LVhnt2 LIC 4lF5*/6.fPhone 925 '3/358, 0 <br /> Consultant/Sub Cntr �S Address.Z$70 Ga{GtvR�t-/0&kS70'a City (AG"-*?e""O Lic Phone 9VP 67923/,3 <br /> Billable Party UIRS Address 3"114f,is-vcity Zip Phone <br /> GIS Coordinates:X .37. 8S I Y^I 2_12y2_ <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELLIBORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL ❑PVC D OTHER O <br /> _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE Q <br /> _0 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:D Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION(Ie Pir Seame Ozone)0 HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: []OTHER APPROX BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth:_ Boning Dia:_ <br /> COMMENTS: ()V6R �)dP I(,1 /7uE 7a r(I DF7Ln— <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:ICHECKALL TFIATAPPLYI <br /> _L#OF WELLS) BE DESTROYED OVER-BORE DIAMETER OF-10 INCHES TO DEPTH OF !! FT <br /> WELL IDs: c gr PRESSURE GROUT TO DEPTH OF //7 FT BELOW SURFACE <br /> GROUT SPECIFICATIONS PC]EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:LI AUGIORSTA HOSE C4 PIPE -MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I h ve prepared this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and I IeEaflfgrOL` <br /> Signed , (/V�!///AG /Z/�/�'A'n1 Title/Company <br /> Print Name "i LOi n-1 k7AcA o Dale <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS //A-c S / fYol'iID fzocl <br /> WORK PLAN DATED JKLsi 2412 i 1 <br /> APPLICATION ACCEPTED BY kilo l4Kuw. DATEISSUED '7-7. 7-12 AREA I f/ <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM E NTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> REQUEST I PR# <br /> 29UZ <br /> $125X t SR# 006407 <br /> 3 37 5 3�5 6 73�sG RO o <br /> PR# <br /> 2900 <br /> C-57 ✓ WC V WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />