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SAN JOAQUIN COUNTY <br /> r ter. DEPARTMENT ENVIRONMENTAL HEALTH D <br /> e LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> irtg <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.siaov.ora/ehd UNIT IV <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 Cross Street Fwt'c Av lk uB'_ <br /> Ciry �j/ry'hFeu Zip—,J5107 APN OQ %L0-;Zy <br /> Property INCo/n t HiIS LTJ e <br /> ITvner - Address -�Y �;nieln (PHker City Cinetl-0n Zip 15,, Phone (195) ilfg- 91o0 <br /> C-57Contractor �-MQ"rn fat Address !1450 d40nur Pert PII City PaeNnn /ardma Lic 906562 Phone-Pik) 1l5-s- A010 <br /> ConsultanVSub Cntr 40E ofyIC US Address Leo FA9A 9 71" F/�191` City -wtru✓I _Uc Phone &0 LSA- ys;ey <br /> a <br /> Billable Party AQ c ) Address �fa, abnw) Clty �rce A6ew- Zip 11160k Phone <br /> GIS Coordinates.X .48.001 Y -12I.3Ai <br /> C N TRUCTION WORK TO BE PERFORMED- <br /> 10 NEW yVELL/BORING(CPT,GEOPROBE,HYDRO CH,HAND-AUGER,ANDUGER,OTHER) <br /> ®SOIL BORING IDs .2 6T�1, S'Z <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE 8#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE <br /> _L El MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> _0y EXTRACTION.vapor/Water ❑I-AMMER/ORWEN CASING THICKNESS TYPE OF CASING: 0 STEEL ❑PVC ❑ OTHER <br /> ,?—q SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> _0 SOIL BORING IX PUSH POINT(GP/CPT) GROUT SEAL PUMPED0 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 Fn <br /> _O INJECTION fl A S pz )0 HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR 0 STOVEPIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth:_ Boring Dia' <br /> COMMENTS: '(8dtll�d�c.:1 haHuf{ w,11 Im AlIW&C d a e dAr <br /> NOTE: rOFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑ PRESSURE GROUT TO DEPTH of FT BELOW SURFACE <br /> GROUTS EXPLOSIVES FROM <br /> 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 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,Aird all appl�eble California-Laws. <br /> Signed Title/Company ffincipal Na,w,eeZAECADIC US <br /> m <br /> Print Nae ) n CSQIQctM e <br /> Date 5�) <br /> �j DEPARTMENT USE ONLY T <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS I Q Lr, 'F i L /l Z_per( 4,0 :F- d- J P I VP -*Ga <br /> WORK PLAN DATED h r tl.,- r, 1 2- <br /> APPLICATION <br /> APPLICATION ACCEPTED BY DATEISSUED 5--"3-/2_ AREA I S <br /> GROUT INSPECTION BY FINAL INSPECTION BY V16I-P riA 01 �Ijow�r, DATE S.]-/Z- <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: A V A <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> REQUEST PR# <br /> a905- $125x D 'Z 5 -3- Z SR# Q(]L G <br /> 'Off <br /> 3600 4 7 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />