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r : i • <br /> opa" SAN JOAQUIN COUNTY FILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> �"` '•, 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> �'`: '•.-� -•'p/r <br /> Telephone: 209 468-3147 Fax: 209 468-3433 Web:www.si4ov.orQ/ehd UNIT IV <br /> P ( ) ( ) <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. �j <br /> 1 � D'� Cross Street I� •Cell: Yn I A Y G City/State ip� APN r` 4 <br /> "ropeSite Location ��` <br /> Owner <br /> V, P( T53 o Phon�u9' �e —(�1 2 <br /> Owner Address , CIvi C l�n ✓ GitCity/State Zip <br /> C-57Contracor i(o P_ Address 1��4 rGe- Sf u ✓L Ay/State d1i%5,k99 Phone <br /> Consultant/Sub Cntr Address 71a I WZI �t.i f , �✓ pity/State Gla Lic bG 6 Phone S(D qk)G <br /> Billable Party CV"V-0y-\ Address 00f City/State,�n_12a*vy\,Zip..I_qPhone 12-5-716 (at'{31 <br /> GIS Coordinates:X YC <br /> CJDNSTRIUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> SOIL BORING IDs <br /> Lj WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIF CATIONS <br /> _17 MONITORING El HOLLOW STEM DIA,OF BOREHOLE —3 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _�JCTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes Z'-'lo(MA;Il UM Fi E F LL DEPTH IS 30 FT) <br /> a l !( Yf�Yt1D,t�l <br /> _❑INJECTION(i.e.Air Sparge,Ozone L�AND AUGER GROUT SPECIFICATIONS�V I Oy'A <br /> .- <br /> '❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING 2PNO[IYes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: 1 <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 N TICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify th I~av pre rod 1 a lication and that t ork will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulatio+2 nd a I bl Calif f(ia S. <br /> Signed Title/Company <br /> Print Name Date t Z I <br /> (}p DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS '1 j� <br /> WORK PLAN DATED (Zu(iR'l I2,0/ Y <br /> APPLICATION ACCEPTED BY DATE ISSUED -ZG'�� AREA I� <br /> GROUT INSPECTION BY T 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 /> -t REQUEST PR# <br /> c) l $ 125x COD do Qf, 2 t6 SR# <br /> *ygo5 37� RO# <br /> o� 3500 <br /> PR# <br /> (2900) <br /> C-57 L", WC WAIVER tf,'4 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT t/ ENCROACHMENT DOCy <br /> FHD99-01 5/09/19 WFII PFRMIT APP <br />