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ot`°t�l c SAN JOAQUIN COUNTY ORIGI <br /> {�q <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> N: <br /> • ` "" 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> '• UNIT IV <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siaov.org/ehd <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 San Joaquin County Environmental Health Department. <br /> Site Location 3440 E I M01'114 $f Cross Street fr'0adway City/State&[_Zip 9.VZO5 APN IS�7/60-OZ <br /> Property <br /> Owner =IJ11-LEE TRUO Address 105W-E/Moate -Jos'wes City/State CA- Zip,HdZZ _Phone )94/-/L952 <br /> C-57ContractorR d r'fdl"4fe Address a# Pblt,YelLCF00ecoWstate CA- Liicc Phond%4369-935Ts <br /> Consultant/SabNMN LAddress#M 4); &t W'.r E QsY411091t'y///taterCv Crd •S3Q Phone(9/dl 93g-2/ O <br /> BillablePartyu��1'IvW4#1 C r Jress/a9s5 tyF� �►f'� $WtW00 y late/�h� 610 Zip IrOf'7Z/ phone 03)�19-✓d9/ <br /> GIS Coordinates:X 31,q Y/V.VgAIV-Is <br /> 37„_95- 1 -/z/-Z4dIt <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 WELUBORING 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 Sparge.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 /> 0 NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> a(�.e4 YW Jo,csO I <br /> #OF WELL( )TO BE DESTROYED ,u ! �- ®OVER-BORE DIAMETER OF��INCHES TO DEPTH OF-P-150 FT <br /> SIM LL IDs:M�/ IfI04IKV-6 4roa&W-2/� C fr W�/ / Vw^Y ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> 3ROUT SPECIFIC 1lectf .CG btr ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> ,4rREMIE TYPE TO BE USED:❑AUGERS fit]HOSE J� PIPE 09 MUSHROOM CAP AT(?3 FT) 3 FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 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 i le CalifomFa4 wa.— <br /> Signed Title/Company?,'Iei Ntr>yd`rr W-P# ar ►✓iYcr/Iraeu�a,Iisc <br /> 3rint Name Date Lt2I0�r�/ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 5 rA66-r <br /> NORK PLAN DATED / 1 <br /> 4PPLICATION ACCEPTED BY _��(oT ti�c•�I DATE <br /> 3ROUT INSPECTION BY FINAL INSPECTION BY Ift <br /> 7ESTRUCTION INSPECTION BY DATE 14 <br /> COM MENTS/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 /> 50Z $125x 2 SR# Q? <br /> 350' 3 7S 3�5 (3500) <br /> PR# <br /> (2900) <br /> C-57WC y WAIVER /VAI C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT d ENCROACHMENT DOC-!U <br /> -HD 29-01 5 09/12 WFI I PERMIT APP <br />