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0 <br /> SAN JOAQUIN COUNTY <br /> ai ENVIRONMENTAL HEALTH DEPARTMENT -LO P <br /> ` a <br /> . t 600 East Main Street,Stockton,CA 95202-3029 SITE MITIGATION <br /> Telephone:(209)468-3454 Fax:(209) 468-3433 Web:www.sigov.orgleh UNIT IV <br /> IFOA� <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 Locatiori W 1445I111'UAAW S'T Cross Street NAVY 0Rr"F City S1ULF-r1n1.(f1 Zip 95206 APN IY501013 <br /> Property <br /> Owner JOAN OFiAfi LAr+uRA•P[? Address 1`3011414 7DSEJt.E IOtAu City NoLtrv15,TL zlprpl-265 Phone 603-821-2062 <br /> C-57Contractor TS(.-l1Ji; L Address II350HONIE1i QAntc?U`1M City 9W11110 Cea00YA LIC7O&SQb Phonecllro-853-9010 <br /> ConsultanVSub Cnb Efw-NEST,Tu4 Address 2525 tUMb101PMt OR#7So City $AL1W+re^'11101 Lic Phone 9(6-124-1379 <br /> Billable Party 1IW1-W45VIJAC Address2T'2f NAn MI ewm OV-s7fo City 5A(R1Mvvt (A Zip 933 Phone 9f6-9'L•(-9376 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER) <br /> ❑SOIL BORING IDs <br /> D WELL IDs <br /> D OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _D MONITORING D HOLLOW STEM DIA OF BOREHOLE D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA:_ <br /> —D EXTRACTION:Vapor/Water D HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL ❑PVC D OTHER <br /> —D SOIL VAPOR PROBE D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS D HOSE D PIPE <br /> _D SOIL BORING D PUSH POINT(GP/CPT) GROUT SEAL PUMPED:D Yes O No(MAXIMUM FREE FALL DEPTH IS 30 Fn <br /> —D INJECTION ne?bSoarneomnel0HAND AUGER GROUT SPECIFICATIONS <br /> _D OTHER: D OTHER: APPROX-BORING DEPTH D BOLTED TRAFFIC BOX OR D STOVE PIPE <br /> CONDUCTOR CASING D No D Yes:Casing Dia: Casing Depth:_ Bodng Ole: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:rcHECK ALL THATAPPLY, <br /> , I OFWELLS)TO aE DESTROYED CROVERBORE DIAMETER OF 9„ INCHESTODEPTHOF 12.OFT (T0) <br /> WELL IDs: N (-1 D PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FTSELOWSURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE D MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS WEw 1,111 ryf- r0M1 L.ETF Y E'GF�7DgTlT/4L DP�N�FLLL JILL YiE ektW--0 n Lr msar r(At/A-V" <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, d 1 applicable California laws. ;1 <br /> Signed G TilelCompany IVbs mork4lu/ r=m -Wy(�',Sme. <br /> Pont Name oh" Li'"(wc Date 27 Vic+ Lett <br /> DEPARTMENT USE ONLY / 1 <br /> SITE MAP IN UNIT IV FILE-SI ADp/�QESS � bU L(J4 J �� <br /> WORK PLAN DATED _ t D/ / �_ i/ / <br /> APPLICATION ACCEPTED BY DATE ISSUED // / _�-OIl ARE4g q_Z <br /> GROUT INSPECTION BY FINAL INSPE�;TI BY DATE <br /> DESTRUCTION INSPECTION BY DATE I(/_ L 'LD0 <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAG# <br /> PE CODES FEE INFO AMT REMITTED CHECK# q RECV'D BY DATE SERVICET PR#RO# INVOICE <br /> C(/ <br /> oZpoZ <br /> $,2tXl (2'� 00143 / /ti .Zot/ REQUESSR#D0G 717 <br /> 2ffl-a? 3?T -97(— - (300 00012-72- <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER G-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD29-Oi 07/2BHO WELL PERMIT APP <br />