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f {a <br /> a°�4- .o • SAN JOAQUIN COUNTY • FILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> SITE MITIGATION <br /> �L.oQ Telephone:(209) 468-3147 Fax:(209) 468-3433 Web:Nsiaov.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 theStandardsof the San Joaquin County Environmental Health Department. <br /> Site Location it, .s Iv �� Cross Street �i�-F�v+�,(L �SJ' -ryJ� �0/Ilff'ity/State ?LWRftI ' <br /> Prope � F-[ �P.9_.'�f�. APN Z���pO�JO-,� <br /> Owner N I/?w Address 2061 -f AAW 7 City/State &*rMZip9S32G Phone 261— pZ400 <br /> C-57 Contractor�AIJIQUXtf I {.) Address U. SOY1 City/State WOU10(a,npLie glut o Phone S-30-2 M--Z/2 u( <br /> Consultant/Sub Cntr Address - City/State Lie Phone <br /> Billable Party Address City/State Zip Phone <br /> GIS Coordinates:X Y -121. A23.g <br /> CONSTRUCTION WORK TO BE PERF ED: <br /> I� <br /> r NEW WELLIBORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING Ips <br /> WELL IDs M <br /> OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> -0 MONITORING 0 HOLLOW STEM DIA.OF 13OREHOLE 2'_L!50 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS SCF}' LIO TYPE OF CASING: ❑STEEL gPVC ❑ OTHER <br /> _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 7 n '�TREMIE TYPE TO BE USED; D AUGERS ❑HOSE ly PIPE <br /> _O SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED;❑Yes �L�N",o(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION p.e.AlrSmme Ozone)❑HAND AUGER GROUT SPECIFICATIONS._ �GtF'jf C/1%✓✓1�CnT <br /> _O OTHER P <br /> ❑OTHER: APPROX.BORING DEPTH SCSI BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING 10 No O Yes:Casing Dia: Casing Depth:_ Boring Dia: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD•(CHECK ALLTHATAPPLY) <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 L3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 1 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,ad H applicable California laws. <br /> __..___.____.___. _- - <br /> Signed-- &� • Title/Company (,IJ IJ�f2_ y� <br /> Print Name ws C C ZA,-, U�I\- Date S /7_ p/L <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDt7-6y)( DDI S' <br /> WORK PLAN DATED A�(9'uSf 2, 1 2014 <br /> APPLICATION ACCEPTED BY .I-H 0FYKuv.1 DATEISSUED S`/cI'/y AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE_ <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CQQ 9S, FEE INFO AMT REMITTED CHECK# IR!ECV'D BY DATE SERVICE RO# INVOICE <br /> g67 REQUEST PR#$125Xuw7'EQ 5-12-1yIRO <br /> sR# 9�L(S <br /> iZof # <br /> PR# <br /> PR# <br /> 2900 <br /> C-57 ✓ WC !/ WAIVER <br /> EHD 29-01 5/09/12 _ I/ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC _ <br /> WELL PERMIT APP <br />