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A <br /> r -41 <br /> N `%Iw' SAN JOA � FILECOPY <br /> QUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP - <br /> 600 East Main Street, Stockton,CA 95202-3029 SITE MITIGATION <br /> �, a-• Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.slnov.orQlehd UNIT IV <br /> WELL & BORING PERMIT APPLICATION Q N <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION T <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED w !� <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 San Joaquin County Environmental Health Department. <br /> Site Location 290 N Main Street Cross Street W Center Street Cit Manteca 95336 <br /> Property y ZiP APN 223-091-01 <br /> Owner Cardoza Enterprises Address 1132 N Main Street City Manteca Zip 95336 Phone(209) 239-4141 <br /> C-57Contractor V&W Drillin Address 3806 Duck Creek Drive City Stockton Lic 720904 Phone(2091 469-7700 <br /> Consultant/Sub Cnti eo ogica Tec c <br /> Ad3ress 1172 Kansas Avenue City Modesto Lic N/A phone(209) 522-4119 <br /> Billable Party Cardoza Enterprises Address PO Box 1022 City Manteca Zip 95336 one (209) 239-4141 <br /> GIS Coordinates:X 3?AOO y--(2-(.2,(G <br /> CONSTRUCTION WORK TO BE PERFORMED: N/A <br /> NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&-#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: w <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER `An' <br /> SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE O <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION fie AE Soaroe.Ozonel❑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 Dla: I <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPY See Table <br /> lO #OF WELL(S)TO BE DESTROYED VER-BORE DIAMETER OF-66t IU INCHES TO DEPTH OFnL±5 jFT <br /> WELL IDs:MW 1-3,&8; MW-104; EW-1 & 2• SG-1 thru 3 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS EXPLOSIVES FROM TO FT BELOW SURFACE — <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSH OM CAP AT L3 FT) FT BELOW U FACE <br /> COMMENTS See Table _ <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 plic ble C ll mia Laws. <br /> Signed � t Title/Company r CI ,W <br /> Print Name 1t,1 S. Date l Z 4 I <br /> ,ryry DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS bzC(o M, Maw Sr. pvogy74f�- <br /> WORKPLAN DATED N0Vr--Y beZ 2P. ?Olt <br /> APPLICATION ACCEPTED BY CJ, 7 bR Kutvt DATE ISSUED ]�.-41-1-1 AREA. F <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COM ME NTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST I PR# <br /> 3502— $125x 10 tLSO SR#00 qot <br /> 3So3 33T 5 DL 2 '�-�'7� (Z-- 1 (300) 532- <br /> 1�Z5 <br /> C-57_ WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT V _ENCROACHMENT DOC <br />