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p L. NOW <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> N:.. ..\. <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Y. UNIT IV <br /> • ° «Fa::.�;:4 Telephone:(209)468-3147 Fax:(209) 468-3433 Web:www.sigov.orglehd <br /> WELL & BORING PERMIT ,APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES I 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. I Ghat 6-�j <br /> Site Location Q-06 jGMA'"Lk )-,-, Cross Street kAA- )n . City/State J c•f tot Zip L7S f'-t Ci APN 104 ,1, � 4: <br /> Property, n F �y <br /> �O: VLAddress Ib2 ;�i1)rf Y <br /> Owner R. 'f' `a ?'+L���1��T[ar.,. .- , Cllti'�i (�r�p�il� Cit/State JR.�_ o,SF,r:A Zip ���•.i`J Phone <br /> C-57 Contractor Y—� 'SDI I(, � Address (4S­ �� , V City/Statjk, �fR����t is ��l�7~ Phone„ ��� >I�'`�''�> <br /> Consultant/SubCntr(r rdn:^ krC Address If1-7t•-bne.Patr,AW,, aI'�.:tulerity/Stateb'�4t�,2f' ?[ Lic Phone 7�^�l�~),:L2i <br /> Billable Party Address City/State Zip Phone <br /> GIS Coordinates:X Y <br /> CO TRUCTION WORK TO BE PERFORMED. <br /> EW WLL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> [9 SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DW OF BOREHOLE ,n ❑MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION:Vapor!Water D HAMMERIDRIVEN CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL J '+ TREMIE TYPE TO BE USED: 2-AUGERS ❑HOSE ❑PIPE <br /> _1113-SOIL BORING Q PUSH POINT(GPI CPT) GROUT SEAL PUMPED:bakes O No(MAXIMUM FREE_FALL DEPTH IS 30 FT) <br /> ❑INJECTION(e rspeAe.Ozono1 E]HAND AUGER GROUT SPECIFICATIONS <br /> __❑OTHER: ❑OTHER: APPROX.BORING DEPTH I fit) ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING 2.00❑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.(CHL-CKALL iHATAPPLYI <br /> #OF WELLS)TO BE DESTROYED E]OVER-BORE DIAMETER Or INCHES TO DEPTH OF FT <br /> WELL IDs: E]PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:[I 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 /> I hereby certify that I have- affi <br /> prepared this applicatia i and that th ork will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and al"poicble C ifornia taws. <br /> Signed -Title/Company ' ?2C 1--e <br /> Print Name a-�. r Date / /�-, (J <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS f 2,0 <br /> WORK PLAN DATED 'd7OlZ <br /> APPLICATION ACCEPTS BY L:� DATE ISSUED 11 AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY _ DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# REGV'D BY DATE SERVICE RO# INVOICE <br /> 1 ✓ REQUEST PR# <br /> �SdS $125x I �Z�r� t'3 �toZ �1 IZ SR100t �o�b <br /> 3S,0 3 7 5- 7� ( o0 <br /> PR# <br /> t - <br /> fz9oo) <br /> C-57 we WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> KHD2R-ni 5/IMM2 WELL PERMIT APP <br />