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�qufy. <br /> SAN .JOAQUIN COUNTY v <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> +` <br /> Telephone: (209) 468-3147 Fax:(209) 468-3433 Web: www.sigov.org/eh UNIT IV <br /> FO� <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 /> 1930 N California St Mc Cloud St Stockton 95204 127-174-30 <br /> Site Location Cross Street City Zip APN <br /> PfoPe ty'St Joseph's Medical Center 1800 N California St Stockton 95204 209-461-6818 <br /> Owner Address City Zip Phone <br /> C-57 Contractor Advanced GeoEnviroAddress 837 Shaw Road City, Stockton Lic 95215 Phone 209-467-1006 <br /> consultanVSGubCntr AGE Address 1800 N California St City Stockton Lic95204 Phone 209-461-6818 <br /> Billable pant Josephs Medical entedddress 1800 N California St City Stockton Zip 95204 Phone 209-461-6818 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMBE ED: <br /> CI-L <br /> ®N II SOIL BORING IDS BORING(CPT,G ine borings lti IO;iL HAND-AUGER,OTHER) <br /> ❑WELL IDS <br /> ❑OTHERIDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1.5 Ine MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS na TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> 15-161`3 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 7 feet TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE ❑PIPE <br /> _0 SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes Ig No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION(i a Air Smme.Ozone)[]HAND AUGER GROUT SPECIFICATIONS Portland <br /> _0 OTHER: ❑OTHER: APPROX.BORING DEPTH eet 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING 0 No 0 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 ALLTHATAPPLYI <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 L3 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,and at PIC I ifornia laws. <br /> Signed WI Title/Company Geologist-AGE <br /> Print Name William Little Dale oq Iii <br /> RECEIVED <br /> DEPARTMENT USE ONLY RE <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS Il C <br /> WORK PLAN DATED PAYMENT <br /> APPLICATION ACCEPTED BY DATE ISSUED L) <br /> !J <br /> GROUT INSPECTION BY FINAL INSPECTION BY -*-5 1111? J flRJ11T <br /> DESTRUCTION INSPECTION DATE �'TQE�)����LTH <br /> COMMENTSICONDITIONS: ENYI <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> Z�nS $125X t (.25� �59 �1 l(J 1D 19/x2_ SR# S <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 01/13/12 WELL PERMIT APP <br />