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oq,4 •lN, <br />�AO <br />P <br />WELL & BORING PERMIT APPLICATION <br />FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br />L) ORIGINAL <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: WWw.sigov.orcllehcI <br />LOP <br />SITE MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application Is hereby made to San Joaquin County for a permit to construct andlor 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 />':, / '70WAY i(G �%� ''7LAPN <br />Site Location '' N AIKI'0Cj' Cross Street 1 0� e�! (ice/t� City/State k Zip �i <br />Property.;. 1q <br />Owner �UtxPT 1�11t%rK� Address ti1C City/State Zip Phone <br />C-57 Contractor r C4tiZ VlL'�t l-Li7 Address � 000 �� n h S CilylState /tC IAlIv'0Lic `17�)!�' Phone !'ib -6�'; �1 69 <br />Constdtant/SubCntr GN1�, lrUC - Address -7Z-3i �G)c7LC�t,CS lA�ru. CitylStaIt ')t�A e Lic b*'1 i170 Phone -f64-7�3-ID/t1 <br />Billable Party `7i > I L: Address `7`'' ` 15-V City/State Zip Phone <br />GIS Coordinates: X i 9 Sis-?( y I e 1- Z J -Z5S -, <br />EW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) <br />❑ SOIL BORING IDs <br />E) WELL IDS LuL S l h1! - 17 <br />t <br />❑ OTHER IDS <br />TYPE & # OF WELUBORING INSTALLATION TYPE <br />.-0 MONITORING 13,HOLLOWSTEM <br />_❑ EXTRACTION: Vapor! Water ❑ HAMMER/ORIVEN <br />❑ SOIL VAPOR PROBE ❑ MUD ROTARY <br />_❑ SOIL BORING ❑ PUSH POINT (GPI CPT) <br />❑ INJECTION If e.A7r Svaroe Ozone) ❑ HAND AUGER <br />❑ OTHER: _ ❑ OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS '�'�'Cl q0TYPEOF CASING: ❑ STEEL O PVC ❑ OTHER <br />DEPTH OF GROUT SEALrI/ ?TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE, PIPE <br />GROUT SEAL PUMPED: Q'Yes ❑ No (,MAXIMUM FREE FALL DEPTH IS 30 FT) <br />GROUT SPECIFICATIONS �1 U- { dt 1(.4 4' ill: i)G •<'F•y"a <br />APPROX. BORING DEPTH I01- S 7T Z.) - L'} BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />CONDUCTOR CASING C1 No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: <br />COMMENTS: <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /># OF WELLS) TO BE DESTROYED <br />WELL IDS: <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />COMMENTS <br />5 WORKING -PAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />I hereby certify that 1 have prepared t(i)s application and that the work will be clone in a cordance with San Joaquin County Ordinances, Rules and <br />ReUulations,and�a plicab <br />Signed L 72 <br />Print Name hY <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />❑ OVER -BORE DIAMETER OF INCHES TO DEPTH OF FT <br />❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br />❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br />❑ MUSHROOM CAP AT (?3 FT) FT BELOW SURFACE <br />Ilfornla law$c' <br />Title/Company <br />r-..'(11 N Data <br />C <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS <br />WORK PLAN DATED AUGuy r M, <br />, <br />APPLICATION ACCEPTED BY�I <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />r0MMrNTSM0NnIT1nNS- <br />LY <br />DATE <br />FINAL INSPECTION BY <br />DATE <br />E <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES FEE INFO <br />AMT REMITTED CHECK # <br />RECV'D BY DATE SERVICE RO # INVOICE <br />RE4UEST PR ft <br />�DI <br />S x <br />Jr'�) <br />I% 3�% <br />N <br />S I <br />SR# OD b <br />RO # <br />3500 <br />PR It <br />2900 <br />C-57 V WC WAIVER <br />EHD 29-01 5109112 <br />C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br />ENCROACHMENT DOC <br />WELL PER IT APP <br />