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+� IL Wei <br /> 0 0.�ln• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> ` SITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> ^ Telephone:(209)468-3147 Fax:(209)468-3433 Web:www.si-gov.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 /> Site Location --Ok S` 3� Cross Street Qfie. City/State .(46 141,Zip APN 1!�jI- Zl- bZ!�j <br /> Property <br /> Owner t r, <br /> meq, Address �'lo r,A.nc C.t.76a tin City/Slate Zip 1S6'3ZO Phone 7p5--14!-�Zzao <br /> C-57 Contractor ()1,J Q n(j�y , Address __360(c, ��c�e C'2ak t o City/State is 2 o Phone lo-,- %t6!5 <br /> -'4•?00 <br /> Consultant/Sub Cntr G:NGFZQ _1 C Address �-W Avert 4M City/Stale Oem/GQ Lic ✓1��_Phone ZDti- 464.7-496 <br /> {{±± ^ ^Ir City/State _�_Zip Phone <br /> Billable Party !��(;� .�nG Address <br /> GIS Coordinates:X 3 3 Y /z( 3010 4f LSF to r <br /> Z,'a ¢ZGotG — 171 3or 66`I <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor!Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ 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 ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ❑INJECTION(i.a Alr Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dla: 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:(CHECK ALL THAT APPLY) <br /> I #OF WELLS)TO BE DESTROYED rt3 OVER-BORE DIAMETER OF I? INCHES TO DEPTH OF_ _FT <br /> WELL IDs: U ❑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(?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 al cable California laws. p <br /> Signed Title/Company erns <br /> Print Name R <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 70� 5�HR7�� �1✓��I L l4T/f2OP <br /> WORK PLAN DATED M A O/ C( <br /> APPLICATION ACCEPTED BY J U 1,4 Ku v-I DATE I AREA ��` 9 <br /> GROUT INSPECTION BY FINAL INSPECTION BY .I,�D4�IG« 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 /> q q/ REQUEST PR# <br /> IU � $125x !. �> �U�tU COCCI �Z 1 SR# <br /> RO# <br /> U 3500 <br /> PR# <br /> (2900 <br /> C-57 v WC WAIVER�1t-1 _ C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC 1-16 <br /> EHD 29-01 5109112 WELL PERMIT APP <br />