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' SAN JOAQUIN COUNTY <br /> «: ENVIRONMENTAL HEALTH DEPARTMENT <br /> "O�"•'• LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> c k8q•• Te%phone: (209) 468-3147 Fax: (209) 468-3433 Web:wwww.sigov Oralehd 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'i09, S•A4fajC}�V <br /> PropertTtCross Street L <br /> City/State <br /> 5(D:0k/d+i Zip UOL45T qL rRoPL.... <br /> q52-64 APN <br /> (4 dg94 3 <br /> C-57 Contractor Address 011Cily/State6t(W0)09'1 <br /> Address _-ek­ZiPlyoPhonec ?aV- r,.,' <br /> COnsultant/Sub Cntr NCAddress City/Stale Lic Phone <br /> Billable Party <br /> City/State .VT - Lie Ct %_&k Phone <br /> '�p7.5?3lao <br /> - _ Address City/State Zi <br /> GIS Coordinates:X Y P Phone <br /> r('IW-6 a4r. 3`f.-145706°, I,orv: .0 , zsdoNsrsr' <br /> CONSTRUCTION WORK TO BE PERFORMED; �w 70 29 -6310 Gd NG 12 , 2 8p g6 5 o <br /> ❑NEW WELLIBORING(CPT,GEOPROB <br /> [1�SOIL BORING IDs E.HYDROPUNCH,HANDAUGER,OTHER) <br /> 19 WELL IDs__�t1 <br /> ❑OTHER IC <br /> �TTYPE 81t OF WELLIBORING INSTALLATION CONSTRUCTION SPECIFICATIONS <br /> �r E(MONITORING HOLLOW STEMrr <br /> DIA.OF BOREHOLE S r� <br /> _0 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN ^ , Ll MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _O SOIL VAPOR PROBE CASING THICKNESS L t . Ua rypE OF CASING: ❑STEEL j].•,QVC 11 OTHER <br /> ❑MUD ROTARY DEPTH OF GROUT SEAL �2-! <br /> _O SOIL BORING O PUSH POINT GP/CP 15- <br /> TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE,�pIPE <br /> _O INJECTION it a&S 0, -,j❑HAND AUGER n GROUT SEAL PUMPED:15 0 No(MAXIM r(1 FREE FALL DEPTH IS 30 FT) <br /> _11 OTHER: GROUT SPECIFICATIONS :�_ 1 Y✓�y plf:rL,�-,ttw 32, KU—A4 I* uq <br /> ❑OTHER: APPROX.BORING DEPTH <br /> ❑BOLTED TRAFFIC BOX OR 11 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING 4 No❑Yes:Casing Dia: Casing Depth:_ Boring Dia.— <br /> NOTE: OFFSITE WELLS 8, BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: <br /> H OF WELL(S) Iv BE DESTROYED DESTRUCTION METHOD: CHECK ALL THATAPPL <br /> WELL IDs: ❑OVER-BORE DIAMETER of INCHES TO DEPTH OF <br /> GROUTS. W. <br /> ROUTSPF ❑PRESSURE GROUT TO DEPTH OF FT <br /> TREMIE TYPE TO BE USED:[]AUGERS HOSE ❑EXPLOSIVES FROM FTBELOW SURFACE <br /> COMMENTS PIPE ❑MUSHROOM CAP AT L3`­FT) To FT BELOW SURFACE <br /> F7 BELOW SURFACE <br /> 5 WORKIIVG.DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify th t I I}a(ia prep 164 tis application pnd that the work will be done In accordance with San Joaquin County Ord' ances, Rules and <br /> Regulatlons,an I It- pplicable alba las. // <br /> Signed h- ._�`GlL-_ PFU.�('�! CGtSr <br /> /� Title/Company <br /> Print Name -,1 - ��� <br /> Date <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS DEPARTMENT USE ONLY <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY <br /> GROUT INSPECTION BY DATE ISSUED AREA <br /> DESTRUCTION INSPECTION BY FINAL INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: DATE <br /> ACCOUNTING ONLY: AID S <br /> PE CODESFEE INFO AMT REMITTED CHECK H FAC# <br /> RECV'D BY DATE SERVICE RO N <br /> REQUEST PR 8 INVOICE <br /> 51252 <br /> SR# <br /> RO N <br /> 3500 <br /> PR# <br /> C-57 WC WAIVER 2900 <br /> EHD ss.m smvrz C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br /> ENCROACHMENT DOC <br /> WFI I_PERMIT APP <br />