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Ilk, <br /> SAN JOAQUIN COUNTY FILE C 4 P Y <br /> y 1 .,;,1lo11 ENVIRONMENTAL HEALTH DEPARTMENT LOP -- <br /> Mr'" <br /> 600 East Main Street,Stockton,CA 95202-3029 SITE MITIGATION <br /> Telephone:(209)468-3454 Fax.(209)468-3433 Web:www.siaov.org/ehd UNIT IV <br /> WELL & BORING PERMIT APPLICATION DFF <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION lir/ <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 San Joaquin County Environmental Health Department. <br /> Site Location Main Street Cross Street W Center Street City Manteca <br /> Property Zip 95336 APN N/A <br /> Owner City of Manteca Address 1001 W Center St City Manteca Zip 95337 Phone(209)239-8460 <br /> C-57Contractor V&W Drillincr Address 3806 thick Creek Drive City Stockton Lic 720904 Phone(209) 469-7700 <br /> Consultanf/Sub Cntr e�oTica Tec n'c <br /> 1d�ress 1172 Kansas Avenue City Modesto Lic N/A Phone(209) 522-4119 <br /> Billable Party Cardoza Enterprises Address PO Box 1022 <br /> City Manteca Zip 95336 (209) 239-4141 <br /> GIS Coordinates:X BOD Y (Z I.,t l(Q <br /> (P2%, <br /> CONSTRUCTION WORK TO BE PERFORMED: N/A <br /> ❑NEW WELLIBORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLJBORING 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 r1 <br /> _,❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i,e.Air Seame.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 /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) See Table <br /> #OF W(S)TO BE DESTROYED OVER-BORE DIAMETER OF ACHES TO DEPTH OF FT <br /> WELL IDs: 5-7 PRESSURE GROUT TO DEPTH OF `154qr FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ��O EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS [IHOSE [IPIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <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 all unlicab nia Laws.o <br /> Signed <br /> Title/Company <br /> Print Name . k Date 12? ei <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE N <br /> TE ADDRESS 29v <br /> A <br /> WORK PLAN DATED /Vc)lXe*7 6E'e 2-2Ga <br /> APPLICATION ACCEPTED BY A D rc Klon DATE ISSUED t;2_-1q-(1 AREA /G `l 9 <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 0 BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> s 125x 3 515 SR# G y v z ► �� <br /> X03 '�75 <br /> R�uTtZ 1,243-(/ °o 'f <br /> PR# <br /> 2900 <br /> C•57 WC WAIVER I C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC _ <br /> 7517 <br />