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• FILE COPY <br /> Wily.;se SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> '• 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> � P Telephone:(209)468-3454 Fax.(209)468-3433 Web:www.sagov.org/ehd UNIT IV <br /> tfF3t <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 3401 RtA f5 Cross Street L•- J City `Q1F�_Zip <br /> yS3'3 APN 15766300--- <br /> Proe <br /> P <br /> r rty 6 // <br /> ow <br /> 'I Address t E City �aa�'f� Zip 94.330 Phone <br /> C-57 Contractor f f�� r1 Address 1 } A tK. City r• nal I) Lic t/ �a Phone ya; 13- f�rX <br /> Consult"trSub Cntr Address City Lic Phone <br /> Billable Party Address City Zip Phone <br /> GIS Coordinates:X Y <br /> NSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ' WELLIDs A4J9CI M ]� W t1S 5F• <br /> OTHER IDs <br /> TYP�E/&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 3 ty MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASPIGS 0 MULTI-LEVELWELLCASING DIA: <br /> —0 EXTRACTION:Vapor/Water Q HAMMER/DRIVEN CASING THICKNESS 5L r^� rp•��T��Y��PE OF fJ1511G: STEEL Hl PVC 0 OTHER <br /> _❑SOIL VAPOR PROBE MUD ROTARY DEPTH OF GROUT SEAL •J I#Slur r"EMIE TYPE TO BE USED: ❑AUGERS ❑HOSE IPE <br /> _O SOIL BORING PUSH POINT(GP/CPT) GROUT SEAL PUMPED: Yes ❑No(MAXIMUM Fish FALL DEPTH IS 3e FT) Jit <br /> _0 INJECTION(I a Nr Soerae.Ozones❑HAND AUGER GROUT SPECIFICATIONS �./ rt7r I <br /> _O OTHER: ❑OTHER: APPROX.BORING DEPTH 7C> WILTED TRAFFIC BOX OR ❑STOVEPIPE <br /> CONDUCTOR CASING No 0 Yes:Casing Dia: Casing Depth: Boring Dia:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: DECK ALL THAT APPLYI <br /> _#OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO 09TH 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 e3 Fr) 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 Jaquin County Ordinances,Rules and <br /> Regulations,,and all ap Ica California Laws. / /• e <br /> Signed /Lsv � Title/Company <br /> Print Name C?9�er�afY koros G— Date )'alIC11// <br /> C <br /> D&EA TMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS <br /> WORK PLAN DATEDMr -'."r`* '` ` _ <br /> APPLICATION ACCEPTED BY j4j DATE IS AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION //11 L DATE <br /> COMMENTS/CONDITIONS: �_M K'R Of -'Sly j5wtlt 16- I <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# .INVOICE <br /> REQUEST FIR <br /> $125x > 7S- l/ IJ/ l 1 ).' SR# 0 —/ <br /> c9.03 5'7� �7S l � 8/ �,� / Zp Il Roo IIbZ <br /> PR# <br /> 2900 SV <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />