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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> y' � '!°t''`':'• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> �` • :.•:� Telephone: (209)468-3147 Fax: (209) 468-3433 Web:www.si-gov.org/elid UNIT IV <br /> c <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 compli_ance vrith San <br /> Joaquin County Development Title,Chapter 9-1115.3,andtheStandards of the San Joaquin County Environmental Health Department. /5 7-.2 7S�o3 <br /> Site Location yOCross Street S 0 2U City/State4„�zip APN <br /> Property <br /> Owner KkCII <br /> C,& Address I`� �"b.orCity/State/Yl.'lI VC,11 pp q'y l// Phonezl,S-30.�-91yq <br /> C-57 ContractorW063wat"I, Dr.11.w,Address QvJ0eV,tky$3City/StateR.oVt4-,t Lic'//OGrI Phone�07-3111-113C0 <br /> Consultanl/Sub Cntr&4 Q Address Zz3S 11,1­4vz7 W.-�l s0 City/StaleSo-4, 4$,,Lic Phone707 3-2 3-/G/0 <br /> Billable Party 6P ID Address 213S (s'O City/State S.KJM Qo3s.•zipgr S-Y0'7 Phone 707,S 13 <br /> GIS Coordinates:X 630 9915,W) Y 17-(GS 3 G.97 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDS <br /> t❑�WELL IDs <br /> r_I OTHER IDs �V- I, . S <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 /> �TIf 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 ri.e.AFSoaroe.Ozone)❑RAND AUGER GROUT SPECIFICATIONS 77 -,a-4 V 00 --'L' <br /> _❑OTHER: OTHER:V+n.�4t7JG 1 APPROX.BORING DEPTHS •� ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING MNo❑Yes:Casinng Dia: Casing Depth: Boring Ola: <br /> COMM ENTS:Tcw.n0r..r./ St t �rU� (. CL4.10 - 610'A- )) ,P•1.« S'- 2-1& C-v /&7-4,,- <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> Z _#OF WFI I(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDS:_' S V-1 V-Z. ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS-r�/u-ZC hd 1-4(—t llt? ,1,, {j c J 0". ( - ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:El AUGERS ❑ HOSE ❑PIPE ❑ MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTST4... !, t,,o t r rr J )�> -t o Jaz �sck F, !(4 e. r .+ (�� - <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared tt}is application and that the work will be done In accordance with Sari Joaquin County Ordinances,Rules and <br /> Regul,ations,-and I app c/abbll Ci rnla laws. <br /> Signed Title/Company �4 7� '*- stn/RG$ <br /> Print NDate 3/y/2o(3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 46 q0 �- • 0.1 S7-;, <br /> WORK PLAN DATED ar-U /G l/ p <br /> APPLICATION ACCEPTED BY l. o(9'f.u,Wl DATE IS <br /> GROUT INSPECTION BY FINAL INSPECTION BY 4 <br /> DESTRUCTION INSPECTION BY DATE 3- <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 /> 2 q 5 <br /> $125x 1 SR# It 7 (2 <br /> 2e/U2 377 RO# <br /> 3500) <br /> PR# <br /> (2900) <br /> C-57 WC _WAIVERA,�4- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC ((il <br /> EHD 2901`5/09/12 WELL PERMIT APP <br />