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o�4uty c <br /> SAN JOAQUIN COUNTY <br /> >.•.�.E.i'••o tLli <br /> DEPARTMENT ENVIRONMENTAL HEALTH DEPA <br /> LOP <br /> y: < <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.ora/eh 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 nvironmental Health <br /> D�e'ppartment. } ` 7�Q <br /> Site Location?0 ��Vy Q Cross Street 1 \,"\ 12 �� bpm City/State C� i "6 �cV d APN l b3� ` y 1 <br /> Property ( P <br /> Owner����C`��Q r✓ � _ (�C � <br /> Address �`\--� ��T City/State ) vzip vl J Phon <br /> C-57Contracto' Ch1Addressl� IllCf�G ���\� R�� City/State' 4 C Li ? <br /> r l�'c1``1,0\\�1�l 1 hon rJ <br /> ConsultantiS`ub, CntrMlKatJ)tJ Address 1U1� ���Q�t(� `��) E City/StateU��ptic phon D �I� <br /> Billable Part& /rC--Drjb� ) Address 1 1 'vCZ c <br /> V� City/State lC (�c,Zip . Lo �Phon <br /> GIS Coordinates:�`I�U �a� �I a Y ���b� , ( � <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION: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 ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION 0.e.Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING❑No❑Yes:-Casing Dla: Casing Depth: Boring Dia: <br /> I NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> D STRUCTION WORK TO BE PERFORMED: <br /> DESTRUCTION METHOD: CH CK ALL THAT APPLY ! <br /> #OF WEI (S)TO RE DESTROYED ❑OVER-BORE DIAMETER OF I CHES 0 DEPTH OF I O FT <br /> WELL IDs:} )- �111�1 ,Nt1L 3 �� �\�\�) ' ❑PRESSURE GROUT T DEPTH OF �' � <br /> GROUT SPECIFICATIONS FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERS ❑ HOSE ❑ PIPE ❑EXPLOSIVES FROM O FT BELOW SURFACE <br /> i' <br /> COMMENTS ❑MUSHROOM CAP AT L>3 Fly / FT BELOW SURFAc <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 /> Regula ions n I a icabl California laws. <br /> Signed Title/Company <br /> Print Name > > l4J Date S <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS S /U{4V'� (06 '5 <br /> WORK PLAN DATED FQ ZC9 <br /> i APPLICATION ACCEPTED BY J. `J v gyCwu.,l DATE ISSUED I/ Z-1 2 AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> n COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE: RO# <br /> REQUEST PR# INVOICE <br /> Q $125 x 12_?Z S R# <br /> u V <br /> z o �� 37 RO# 4 <br /> (3500 <br /> PR# <br /> zsool <br /> C-57 WC WAIVER. /1 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _/ENCROACHMENT DOC _ <br /> EHD 29-01 5/09/17 <br /> WELL PERMIT APP <br />