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SAN JOAQUIN COUNTY <br /> ' ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> Telephone: (209) 468-3454 Fax: (209) 4683433 Web:www.sigov.org/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 /> OrciAc Ane. e <br /> Site Location 64/15 A l�lar.l'ic Am- Cross Street pe, (.9 Oo .f City ShaeLFan Zip 95287 APN 049 -We-Z.9 <br /> Property Metro Apapr T r/e <br /> Owner (r<a {{F��i (awnj3.C�_ Address X100 /aJ/a* 7a-un Ar 12e1 City QcrAw mfy Zip 15p26 Phone rq/(5)?Rd-,4AOo <br /> C-57 Contractor Zr& -Ablflffrh &I Address /f350 ke"I'er Dark 0(A" City &krI4, ('Ar.Vo1a Lic 306568 Phone 853- Ro/0 <br /> Consultant/Sub Cntr APXAnIK US Address ,Ciro &12,[o.d1 Shr ?fF fleet, City Fovrrrwll0 Lic Phone �SL0 651- f1.So0 <br /> T <br /> Billable Party AfCAnK ILS Address wo 41.w City�aa e{aiw) Zip /608 Phone �reu n/ w) <br /> GIS Coordlnates:X -V. 010 Y —IZI. sx2 <br /> C NSTRUCTION WORK TO BE PERFORMED: <br /> NEV46 r!-UBORING(CPT,GEOP50BE,HYOROPUNCH,HAND-AUGER,OTHER) <br /> m SOIL BORING IDS / /S'f-5) <br /> ❑WELL IDs <br /> ❑OTHERIDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE /' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> —0 EXTRACTION.vapor)Water 0 HAMMEWDRIVEN CASING THICKNESS TYPE OF CASING: O STEEL 0 PVC 0 OTHER <br /> V <br /> j SOIL VAPOR PROBE 0,�t MUD ROTARY DEPTH OF GROUT SEAL �_TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> W <br /> _0 SOIL BORING PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes O No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION('ear Soeme 0zane)0 HAND AUGER GROUT SPECIFICATIONS Alear enp t xf — Th <br /> _0 OTHER: 0 OTHER: APPROX.BORING DEPTH -W, 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING 0 No❑Yes:Casing Dia: Casing Depth: Boning Die: <br /> COMMENTS: TeWpOtiabf Swilo <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGRE tENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRU ION HOD: HECK ALL THAT APPL <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 L'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,and/pII appllc `alifomia Laws. <br /> Signed / � c -- Title/Company Aimcilizal .ver/ARCADiS (IS <br /> Print Name` IUr c (v fcec 1? Date 5//4- <br /> �7 DE/PARTMENT USE ONLY \_ p <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS T�l�17 G Qf BI <br /> Bert !7 A l f �L!i ✓'G 't`fJ <br /> WORK PLAN DATED .26 ]z <br /> APPLICATION ACCEPTED BY 1 � � �- DATE ISSUED � .� /Z AREA !zlS—f <br /> GROUT INSPECTION BY V!,-+&-r,4 Y!?�L'Q//1M1E� FINAL INSPECTION BY ✓�GTyy:-el e�4r�1s�, DATE •5-7-) 1 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: AdV <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> REQUEST I PR# <br /> s $125. 1d 4417 -2-13 SR# 066 486 <br /> RO# <br /> 3600 000 I 7 <br /> PR# <br /> 2900 <br /> G-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />