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SAN JOAQUIN COUNTY - " <br /> 2` --err-. '•� �.,.J' <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> L <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> " — ( <br /> Telephone: 2 <br /> <jF�"pHYP p 09) 468-3147 Fax:(209)468~3433 Web:www.si-goy.org/eh 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 rite,Chapter 9-1115Y-�3,and the Standards of the San Joaquin County Environmental Health pepar�eDL r7 <br /> Site PropertyLocation 3 R3� ,u utfd/" Cross Street City/State JT ^�T//DN P Q' .2 APN 3o't'0qD'"L ` <br /> Owner. 6rlll!es Address 393/ /Ueul 6J &AD City/Stat.. �C7riµ/f�P q A&5 phon � �21� <br /> C-57 Contractor "/A Address <br /> eonsultamlVlvi <br /> isubcntr < , p Addressrb 8 � n City/State LIG Phone <br /> 0 //sz Wd£e�ry�s� phone 36364-99Z/ <br /> Billable Party S, fes-, /VIV/� Address S elb6 U 2 Ciry/Stae <br /> cls CoordlvtaDes:x 3�•4`/S 44 r -f z(, �S �P Phone <br /> CONSTRUCTION WORK TO BE PERFORMED <br /> HEW WELUBORING(CPT.GEOPROSE•HYDROPUNCH•RAND-AUGER,OTHER) <br /> SOIL BORING IDs <br /> WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS -5 U <br /> _❑MONITORING D HOLLOW STEM DIA.OF BOREHOLE r <br /> ❑MULTIPLE CASINGS❑MULTI--LEVEL WELL CASING DUI: <br /> _❑EXTRACTION:Vapor/Water ❑.HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL 11 PVC D OTHER <br /> ,❑SOIL VAPOR PROBE D MUD ROTAR❑PUSH POINT Y DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS 4a ❑HOSE ❑PIPE <br /> / <br /> t_4cr.SO1L BORING (GP/CPT) GROUT SEAL PUMPED:❑Yes 5NO(MAXIMUM FRE,/FALL <br /> �DEPTTH�IS 90 FT)1\�rI GU 1G1-j S�Lw.4AgI,�s <br /> —D INJECTION('a Ar Soa,oe 0 +.HAND AUGER GROUT SPECIFICATIONS 60�=KT'r/� W/Tr1 -oft+t�-"T,�.y NCs9 rN•/lo <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH O-Ir K ❑BOLTED TRAFFIC BOX OR/❑STOVE V PIPE <br /> COMMENTS: - `-_ <br /> Ca <br /> CONDUCTOR CASING D NO yes:Casing Dia: Casing Depth:_ Boring Ola: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCr10N METHOD•rcHEGK I THAT APPLY) <br /> ---*OF:W ELL($)TO BE DESTROYED ❑OVER <br /> GWELL ROUTSPECIFICATIONS -BORE DIAMETER OF INCHES TO DEPTH OF PT <br /> ' ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> TREGROUT SEl EXPLOSIVES FROM To FT BELOW SURFACE <br /> COMMENTS M TYPE TO BE USED:El AUGERS f--]HOSE ❑PIPE El MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> CO <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and II appli We California laws. 1 <br /> Signed . 1-r rrtle/Company DCUNE/� ✓` U/,O- <br /> Pint Name —.Sw/ �, /� V/fc Date <br /> G 4 DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 3 I J 1 '//U 41 T�/� 1C�/H.1�� c5?p1<"/'6N <br /> WORK PLAN DATED O Q :L 1 y <br /> APPLICATION ACCEPTED BY_�ft r DATE ISSUED L._'/S— AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITION& <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 356 S $13o x spa 715-6 Z <br /> 35�3j 316 25N <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 ✓ WC V WAIVER_4�4�L C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC /'//EHO 29-01 7/24/14 <br /> WELL PERMIT APP <br />