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SAN JOAQUIN COUNTY <br /> `may ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> 1 d:=• 'P Telephone:(209)468-3147 Fax:(209) 468-3433 Web:www.siaov.orulehd 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 S. I'<}+:;_., I Ga Ad— Cross Street r-S-8 L, City/State Trac Zip. 9S-3-7-2APN Rte <br /> Property �1 —3 <br /> Owner S�.„ "feNw (o -4, Address /f/0 IVRn,-�I TA-� City/State5tf-tffo� Zip TS--Zb,- Phone <br /> G <br /> C-57Contrector C-�f_.4 D.,_0r Address 1672 C.-" L'r L City/State Aa,,.L„ Gzt,..Lic 93 8)10 o Phone 916- 639 -11� <br /> Consultant/Sub CnV_ /}2eAOrc Address _55e 6(..... A- S,_,.{c IIT City/State Fok.,, Lie Phone Flt- <br /> Billable Party Address City/State Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> IS NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> IS]WELL IDs As-2 _d 1, AC-L' <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING <br /> IN STEM DIA.OF BOREHOLE � ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _O EXTRACTION:Vapor!Water ❑HAMMER/DRNEN CASING THICKNESS TYPE OF CASING: ❑STEEL 10 PVC 0 OTHER <br /> _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEALI ��-Ia5-7 TREMIE TYPE TO BE USED: ®AUGERS 0 HOSE ❑PIPE <br /> _❑SOIL BORING 0 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> , ,®INJECTION fie�L$ye-Owne)0 HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: 0 OTHER: APPROX.BORING DEPTH I I L ®BOLTED TRAFFIC BOX OR []STOVEPIPE <br /> CONDUCTOR CASING IR No 0 Yes:Casing Dia: Casing Depth: Boring Dia:_ <br /> COMMENTS: L�.\Lro A { P - F c P' r 1 a4,1 <br /> NOTE: OFFSITE WELLS 8r BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: pESTRUc nON METHOD:(CHECK ALL THAT APPLY) <br /> _#OF WELLS)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 70 FT BELOW SURFACE <br /> THEME TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>_3 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 all applicable California laws. <br /> Signed JS[- a✓P^- Title/Company A R c 1�/D��2 c <br /> Print Name i k. P-W1.4 Date 10hal'-L <br /> DEPARTMENT U ONLY <br /> SITE AMP IN UNIT IV FILE-SITE ADDRESS Z�77S q.!-0 G6� LCkC! ' 7D i <br /> WORK PLAN DATED 10 1 1,4 t-L Tz <br /> APPLICATION ACCE D BY DATEEA 22 7 <br /> GROUT INSPECTION BY FINAL INSPECTION BY )ATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE PO: # INVOICE <br /> REQUEST R# <br /> S61 $125x 14 S�50 ysd (612-T11 SR#056&6ZZ <br /> o 175 37S - qr65- ( LT// # D <br /> -37 <br /> PR# <br /> 2900 <br /> C-67 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />