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a P0.11N. SAN JOAQUIN COUNTY <br /> F I L <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION <br /> 0l I 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> • c � P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sigov.orglehd <br /> �iFORN <br /> WELL & BORING PERMIT APPLICATION ® j� / � <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REM I V <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` SS )) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made'9�orkgnYlwi h San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. (>Li 1180v <br /> at on N d 51, Cross Street t-orre.�( AVe . City L u d I Zip ENVIR, ENTALNEA TH <br /> Site Loc <br /> -Sac fr,:mtt�1 PERMITrSE ES <br /> Property, <br /> Owner CC +jx,6b1a!►%'�,n Address ��Q N SG1t'Y)rnzn�� �t. Cit LOdi Zip_ Phone <br /> IV, .� lo� 'hone <br /> C-57 Contractor 7f q_fx� Address '>�5 35 / B�hJ ley Sad'- I FKS%/C Lic <br /> Consultant/Sub Cntr j 6-9f-ALC� Address %h%b;Z H,ll-Kgn .Atk City ;tKVaa/7 Lic Phone i4'Y l)d ba- 97/B <br /> Billable Party IaS_CM.'1.) CI; Address City Zip <br /> �qt Phone <br /> GIS CoordinatesJ•X C, Z Y —/2-1.9;Lj <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ®NEW WELL/BORING(CPT,GEOPROBE.HYDROPUNCH.HAND-AUGER,OTHER), <br /> 9 SOIL BORING IDs !,V-1 , SVS 113-3 S'y'�, B h mill b"l <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _[ISOIL VAPOR PROBE 1­71MUD ROTARY DEPTH OF GROUT SEAL R/ TREMIE TYPE TO BE USED: E]AUGERS Id HOSE ❑PIPE <br /> 4 SOIL BORING PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes No(MAXIMUM FREE FALL DEPTH IS 30 FT) O <br /> _[]INJECTION(i a AirSoarge.Ozone)El HAND AUGER GROUT SPECIFICATIONS )91 n"loi9'I� CeMrn!lJV,X`ly 9- <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH (S-16) ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING 0 No❑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:(CHECK ALL THAT APPLY) <br /> #OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: P` ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS SE ❑ 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,a all applicable California laws. <br /> Signed /�-t' ' Title/Company SEiNIOK PR03MCZ MAN,`heR ��Rf,•.toN <br /> Print NamQt 1►RL 3- PER tIIZ A Date `r/`1 111 <br /> -7 DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS ( 1O S 0R19"le? l70 sTR'tC r ' U <br /> WORK PLAN DATED O -I <br /> APPLICATION ACCEPTED BY u!� AREA <br /> GROUT INSPECTION BY FINAL INSPECTION DAT <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 PPR# <br /> 71105- $12Fx I L.. �(� SR# <br /> 900 <br /> G-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT OC <br /> WELL PER ITAPP <br /> EHD 29-01 07/28110 <br />