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z <br /> OP°•�'"- r✓ SAN JOAQUIN COUNTY <br /> �.• �.�.r•-PO <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> IN ki '�+'�j ' 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.omq/ UNIT IV <br /> Q-6 <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�S,aan Joaquin County Environmental Health Department. n�/� (� <br /> Site Location W4 5, LAA(.tAo St Cross Street l�'�/�+ UJfry A(A)UZI city S�Lk "� Zip AP N it "✓ J'V <br /> Property tt ((�� CC��� G <br /> Owner M01 JNc Address P,0j(r ,;IG�AOY) 1,561 f.' City Zip / 71J�+ Phone ZOy'�5�3-55(G <br /> C-57 Contractor kkk JGat1 Address' 11'J(►I{/cVikviG�iS(t�W­1 City I kWw 56/,10LlpLiicS357 Phone Sj���7-/��rl <br /> Consultant/Sub Cntlr Ji^OVi r I�xddress 3330 C4Inff-1U.I`V.'55D City <br /> //CA0%-+1!�►,IIC�7tyOL4e Phone .50 �/_7!0'2*Z <br /> Billable Party%r%W S L JVi(royj ,.M(. Address�� lgvriP i✓�. t7 CityLytr�i.,(�. -P t5L8Z Phone J✓�If f�-.Z"t0 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,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 ❑HOLLOW STEM DIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN 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 ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i e.Air Soaroe.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 /> P/llVIrENTS: <br /> -JyJ L9 NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED:PAW-IIS SGW 3jS6W-U)S&w-S DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> Ito #OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELLIDs:F}s I /�S-j,f�52 (f;r!-I VW Z,vw 3 mw-'3 h1w-2 �w-5 r�1w-12W,❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONSt_'A4.T Ona , ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> �?) TREMIE TYPE TO 1B 4SED: ❑AUGERS ❑HOSE E-1PIPEE3L> <br /> MUSHRQfOM CAP AT 3 FT) FT BELOW SURFACE <br /> COMMENTSQVtJ LIVW1Uig-3,S&,-1iT_ S J-S AdSkd �,-ydQll !)firs <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 all a plicable California laws. <br /> Signed uok Title/CompanyPS Cd 4 / �p$r 5 ✓f/�N"S�/F 1d1�Y//i�.e/aL �.�r <br /> C <br /> Print Name 5 j i , c'— Date 2 f'� ZD 11 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED AA�� <br /> APPLICATION ACCEPTED BY /yG� DATE ISSUED 3 AREA /YS� <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 2162- $122x IS 1330 Z5052- CN�"�Z SR# 0� 2076 <br /> Z9o3 3�4 36`;1 z5a3Ro# <br /> 3500 <br /> PR# <br /> -T (2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 WELL PERMIT APP <br />