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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> < SITE MITIGATION <br /> -• 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> �q�iFoaT��o Telephone:(209)468-3464 Fax:(209)468-3433 Web:www.siaov.ora/ehd <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 /> AuF <br /> Site Location 1-177 W. VdSIFM 01E Cross Street F/S-48AG9 RO CityWA"'r-50F Zip APN <br /> Property <br /> Owner KA•1S61R PEam Address 2 t"agm Ir n 50-?71-5110 <br /> ;AZA City 0i4KLwD Zip 9%11- Phone J!0'?7 l-5410 <br /> C-57Contractor VIRGMIrsx Address Noil CIrA«C-Nbf D/Z- CityC-diVcOA9 Lic"105"U'? Phone 92S-•gili`6970 <br /> Consultant/SubCntr PADRE Address-;6u 6XP/-&&6Q. OR. "V city JACMMA9012>Lic 334W Phone <br /> Billable Party FA D 2 Address -T0446 AS AiP Vis- City Zip Phone <br /> GIS Coordinates:X Ct Y (- y/°6t <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEWINELL/BORING(CPT•G OPROBE,HYD OPUNCH,HAND-AUC�R,OTHER) <br /> SOIL BORING IDs I1! / • Lm-1. . 0.4 —S <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2 ❑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 ern TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE PIPE <br /> KSOIL BORING *USH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes KNo(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —[I INJECTION(i.e.Air Soarge.Ozone)El ,• <br /> HAND AUGER GROUT SPECIFICATIONS t o L 0 1, 17 6 a-//?3 t <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 0 15 r ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE <br /> CONDUCTOR CASING No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTSJF GW ENC6­w7'6RISAi SArtPLA LPJ14- 0a CbL'-fic Ti O" A97Ectffsb 6Jo2llP� <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 WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑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 /> 1 hereby certify that I have re red this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations, d applf allfornia laws. <br /> Signed iy Title/Company ' AOS&CT 69*6Ca6l fT PA'D/1X -lc+L, <br /> Print Name h L q^V CX iAC if/L 4 Date /!'•2J-/a <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY 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 PR# <br /> $122 x SR# <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 WELL PERMIT APP <br />