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1 <br /> * SAN JOAQUIN COUNTY 0 FILE COP Y <br /> -Crr <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone: (209) 468-3147 Fax:(209)468-3433 Web:www.silOov.ora/eh UNIT IV <br /> -0�rFOP ` <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 10947�qr, �+f� �J Crass Street S•T ISn kt- City/State,S ck , IZip �t c,1/e APN O O <br /> Property I ``'' q 11 '' <br /> Owner Sh AA �m6rT6n Address 6%7 CO rro Q) City/State i RLI Zip`1C.11S Phoned 5t6 - R647 <br /> C-57Contractor r:Ili� Address rIS� �nWf. �. City/State(�o AI (ALic 4s 9- Phone I1�- 070Z <br /> ConsultantlSub Cntr /�r - Address ! c , S,•�e City/State rc VI�r• ( Lic, �Phone��d• ala`kfg <br /> Billable Part74 Covr(( W,r..Trt. Address <br /> Y � � City/State L r. 'Zip rlSyy9 Phone,�6 -�7.a�Lf}Op <br /> GIS Coordinates:X ae <br /> Shu" y�- �_IeID_I I�.S�• J I <br /> �7< <br /> C NSTRRUCTION WORK TO BE PERFORMED: <br /> r NEW WELLBORING CPT)GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> [SOIL BORING s a Gp? C(J1LRj- <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLSORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLES 0 MULTIPLE CASINQS 0 MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS AYA TYPE OF CR SING: 0 STEEL 0 PVC 0 OTHER <br /> —0 SOIL VAPOR PROBE 0 <br /> MUD ROTARY DEPTH OF GROUT SEAL/,'- //J' REMIE TY E TO BIJE USED: ❑AUGERS ❑HOSE PIPE <br /> 1141 SOIL BORING I! PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes [I No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION(i.e Ar Soame.Ozone)0 HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH SAO <br /> COMMENTS: El BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING No 0 Yes:Casing Na: Casing Depth: Boring Dia:_ <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(L3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 1 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 /> Regulationsra, pplicable alifornia law <br /> Signed Title/Company /,,. !rli S��,TY- C7e D !r7 S <br /> AL <br /> Print Name Dffie <br /> -,p'/aDEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 1KI TdO QQ�CLS &309 t S 7Z`lf'�ti <br /> WORK PLAN DATED --J`4Nkn2 J?17I r <br /> APPLICATION ACCEPTED BY <br /> __j-jO 2'Ck✓✓j DATE EA <br /> GROUT INSPECTION BY FINAL INSPECTION BY D TE <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 /> REQUEST PR# <br /> ga2J $ 130x / LPzS �CGtNJ'T�2 -/.f� fS SR# /7s7 <br /> 3 00 <br /> PR#02a <br /> z90o 534 77 <br /> C-57 ✓ WC ✓ WAIVER 4,0= C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT i ENCROACHMENT DOC <br /> EHD 29-01 7/24114 WELL PE MITAPP <br />