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� � <br /> oaR� 17. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> SITE MITIGATION <br /> UNIT IV <br /> Telephone: (209) 468-3147 Fax: (209) 468.3433 Web: www.sigov,oralehd <br /> �iil cl <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE E 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 /> j� Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location (080 Wi1.hd 1411! AK Cross Street IAM1 I4V1 'Dye City/State 6_ Zip 952.0 r APN ( 4 Z "' 030^0Proertr <br /> Owner yTO& Of 5>jP6Ve'tWn 1 Address 2201 W"hl SiY�td city/StatePIT <br /> 4:10VZip 'TS7.01 PhoneCZO4) 1 `?& -pzfF <br /> C-57Contractor Address120 f . 2d -F-yRi GirMMd CllylState RicfixvLd Lio IO Pnon Sral c/ 76 • o8-CS <br /> Consultant/Sub�CCntfr (pA Address lLS� N : Fir6t S+o 9k ity/State Uos GO& Phone C7 # ' r1917 <br /> Billable Party �Y\•��l ro1V Address I � CRY/State <br /> Zip (y Phone r <br /> GIS Coordinates: X 37* I S67OW Y I ZI . $ 9171170 <br /> CO STRUCTION WORKTO BE PERFORMED: <br /> NEW W�19LLIBORING (CPT, GEOPROBE, HYDROPUNCH, HAND- UGER, OTHER) <br /> [s]"SOIL BORING IDs I 2� <br /> ❑ WELL IDs <br /> ❑ OTHER IDs <br /> TYPE S # OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE Z ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION: Vapor/Water ❑ HAMMER/DRIVEN CASING THICKNESS _TYPE OF CASING: ❑ STEEL O PVC ❑ OTHER <br /> '_O,❑]SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEALT'e I .S TREMIE TYPE TO BE USED: ❑ AUGERS Cl HOSE ErPIPE <br /> (�7(LJ SOIL BORING O PUSH POINT (GPI CPT) GROUT SEAL PUMPED: IYYes O No (MAXIMUM FREE FALL D% EPTH IS 3�0yFT) <br /> _p INJECTION 119 ,NrSmme. OzunalL+PHANDAUGERet GROUT SPECIFICATIONSP�t-•r10 OF' &6t10'P' Buil t -F� -rtI' roS' of <br /> _0 OTHER: ❑ OTHER: APPROX, BORING DEPTHI ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br /> CONDUCTOR C��,sSING @`No U Yea: C sNp Dia: Casing Depth: Boring Dia: <br /> COMMENTS: W�- ?Yygf :tywA (L 2L qA JZ rLLLrIAP�hS' R0Z alt iv lf- fe !JO"✓OL+E—� <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD• (CHECKALLTHATAPPLYI <br /> # OFWELL(S) TOBE DESTROYED [I OVER-BORE DIAMETER OF_INCHES TO DEPTH OF FT <br /> WELL IDs: ❑ PRESSURE GROUT To DEPTH OF Fr 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 /> 111 0certify that I have pre Bred this application and that the work will be done in accordance with San Joaquin Cogoty Ordinances, Rules and <br /> Regulations, an 1 app Ica e a orn aws. /�� <br /> Signed Title/Company tjf ^1 & rfl"f <br /> Print Name AAVL 0 &Si(Ajtkt4j <br /> Date 3/274r <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS � 3 C2 YJ2t <br /> WORK PLAN DATED . I l <br /> APPLICATION ACCEPTED BY DATE ISSUED 3- ZS — 1 AREA rGGG <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID # FAG# <br /> PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE RO # INVOICE <br /> r1of <br /> REQUEST PR # <br /> �0 125x V7JV Co LarvTGQ `� -20-/t/ <br /> SRO rl 92 <br /> W <br /> 296 3 3 75 RO # <br /> 3500 <br /> PR # <br /> 2900 <br /> C-57 WC WAIVER LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 5109/12 WELL PERma APP <br />