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SAN JOAQUIN COUNTY FILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> "• �/� 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> \'. <br /> N:P Telephone: (209)468-3147 Fax:(209) 468-3433 Web:www.sigov.ord/ehd UNIT IV <br /> LiFOAi <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 /> 'b <br /> epartment- <br /> /� <br /> Site Location Z7-�3`i M w.pdS�Cross Street �adn'S R CitylState t;rc—�" Zip 5 32� APN !��� <br /> Property 7 <br /> Owner 5`'1 So,��� G,N.f� Address `�`� /�aZL� �t'`<- City,`State 0aA'm Zip 5 SZ� Phone �Z�S)rlvY' <br /> C-57 Contractor V sM/ a r:11.h5 Address 31-z'Co �uc,L- Llrz e4 D/ City/State 5�Uckh­ Lic Phone (2e9) <br /> Consultant/Sub Cntr Address City/State Lic Phone <br /> Billable Party .gprt EnLJ4,6k -4\ Address 112-q-( Pti r, g c--!!q City/State <7o(d(t,-tip Phone �4ru�851-or�c{ <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT.GEOPROBE,HYDROPUNCH.HAND-AUGER OTHER) <br /> ffSOIL BORING IDS 5(3- ( r Sia- 2 S r�- 3 <br /> WELL IDs <br /> ❑OTHER IDS <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE L ❑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 — /c7 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.Air Soarae Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ICS r t cf ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> 1 CON UCTOR CASING❑No C]Yes:Casing Dia Casing Depth Boring Dia: <br /> COMMENTS: Pus `r'`^S �� — 1--f b 5S <br /> NOTE: OFFSITE WELLS $ BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLYI <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER of INCHES TO DEPTH OF FT <br /> WELL IDs: ❑ 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 ❑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 hi erprepar this applicat' nd that-the work will be done in accordance with San Joaqu' County Ordinances,Rules and <br /> Regulatira d all ap icable li rnia laws. //,/,/ <br /> Signed TitlelCompany '"l�ct �ea�o r S7 �tl vrrr/Kc� T�C. <br /> Print Name 4/UA UcL✓L d«, p,,L� Date 1/51/ 3 <br /> �7 DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS t- 2q 3y 117g2(P6S'4 65C?&&A') <br /> WORK PLAN DATED 2- r 3 <br /> APPLICATION ACCEPTED BY jjDATE IS <br /> GROUT INSPECTIO14 BY FINAL INSPECT ON BY TE q-&-13 <br /> DESTRUCTION INSPECTION BY DATE <br /> CO MM ENTSICO NDITI ON S: <br /> ACCOUNTING ONLY: AID FAC# <br /> PE CODES I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE Rio# INVOICE <br /> I REQUEST PpR# <br /> ( �� I $125x (�. SC� Cnu�vT�P- SR# (0 I S� <br /> RO# <br /> C� (3500) <br /> PR# <br /> (2900) <br /> C-57 ✓ WC 1/' WAIVER 11,14 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC�� <br /> EH D 2961 5,09,12 WELL PERMIT APP <br />