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°a4 '" ` • SAN JOAQUIN COUNTY • ��: <br /> L� —cis, '•.Z <br /> ENVIRONMENTAL HEALTH DEPARTMENT C <br /> ro) <br /> OP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone:(209) 468-3147 Fax-'(209)4683433 Web:www.siqov.org/eh UNIT IV <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLSAND BORINGSUSEDFOR 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 instal the work described This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3-and the Standards at the San <br /> �7 Joaquin County Environmental Health DeparGuenL <br /> Site Lacabpn393 IUP dN �C°��trcet c•' `-'� � <br /> Property City/State 5� J LP cia APN i 3a-0go-t I <br /> Omer <br /> - KcIej Address 393/ Ak"j-16POAD Cay/Stat.. nS- <br /> C-57 Contractor "/A Address <br /> CosultaUSub , City/State PhoneddressR) <br /> 'Ste IzzY <br /> Bilwe Party_ ', fr, /t/f V 1Add Pnorle zo 9- 36 9-4Y2� <br /> Address 4 s <br /> a 66 U e- city/State <br /> GIS Coordinates:X 3�•`I`(5 4 G Y -f 2(, 2$ ZIP Phone <br /> rl&vRe I o—F (i17p7�m✓1 <br /> CONSTRUCTION WORK TO BE PERFORMED <br /> NEW WEWBORING(CPT,GEO 21 E,HYDROPUNCH•HAND-AUGER OTHER) <br /> SOIL BORING IDs <br /> WELL IDs <br /> ❑OTHER IDs <br /> TYPE&*OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 1"rl1 <br /> V <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE /1 pLr <br /> ❑MULTIPLE CASINGS[]MULTFIJ=VEL WELL CASING DLA-- <br /> -0 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC 11 OTHER <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes WINO(MAXIMUM FR�,F7 FALL DEPTH IS 30 FT) <br /> _OINJECTION T ni So o ',HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: ❑OTHER: APPROX BORING DEPTH 1�-s<r n BOLTED.PwFFI �- <br /> -L•+[[..I/I)/1 f -C BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING❑No p yes;Casing Dia: Casing Depth:_ Bodng Ole. <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD•rCHECI(ALL THAT APPLYI <br /> _#OF W ELL(S)TO BE DESTROYED Ll OVER-BORE DIAMETER OF INCHES TO DEPT{OF <br /> WELL IDs. ❑PRESSURE GROUT TO DEPTH OF FT <br /> GROUT SPECIFICATIONS Fr BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> COMMENTS ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <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 he done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and ll appli ble California laws. �1 <br /> Signed ` . ---r Tide/Company O1f.,UfVel� ,j, U/Q. �j'f'a/G 15—/ <br /> Print Name 7G.oa� �- Lj/I've <br /> / Date 2 /3 / S <br /> J p DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-FFSITE <br /> ��ADDRESS J i 3 / 1L)"--Lt)7011] k6AD 5?W<�64) <br /> WORK PLAN DATED C)o roe6lQ� 2 X31 y ,r� <br /> APPLICATION ACCEPTED BY ., . 1 fJ/,STT u� DATE ISSUED iZ'r7'1 S— ARFA <br /> GROUT INSPECTION BY <br /> FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS:. <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PRO <br /> �Sb s $130. 7- sRal 71 2- <br /> 35a) <br /> 35a) 3Y6 RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 ✓ WC V WAIVERi//� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT y ENCROACHMENT DOC <br /> EHO 29-01 7/24/14 <br /> WELL PERMIT APP <br />