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• • <br /> • e,;F; , SAN JOAQUIN COUNTY � ! LE COPY` <br /> 1.n4`r 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,sigov.org/ehd _.__.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 wtth San <br /> Joaquin County Development Tille,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location F501 D)�KW Cross Street $- /Iwr tA, .1 City/StateL Tµ4-IF Zip 5533 L7 APN 14$-13-0 1 <br /> prop" �tV <br /> Ace <br /> Owner RlatAnn Cay Rct44s LP Address 4/oJ OoGT/�j4lE' ClrylState{� �t'c•� Zipesyeo Phone 4k4-1141-10/0 <br /> C•57 Contractor V—NqE TLuF. Address t?J . ai:4 -74 t City/State UFCcJut..A Llc 914'T1p0 Phone 53z-a tet- aL I <br /> ConsullanUSub Cntr$t►tjt-EC Addreas3'10 U la:C.ET CU fTL2lry/state ur CL,Lic Phone 445-946.21aLI <br /> Billable Party Address City/State Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER) <br /> o SOIL BORING IDs _n <br /> ❑WELL IDs U I J <br /> ❑OTHER IDs <br /> TYPE d#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ENVpIIPppOopNME��N.CCTALHEALTH <br /> _❑MONITORING Cl HOLLOW STEM DIA OF BOREHOLE•g« ❑MULTIPLE CASINGS❑MULTI-LEVEL WEL iMSESNICES <br /> _❑EXTRACTION:Vaporl Water ❑HAMMERIDRNEN CASING THICKNESS TYPE OF CASING: ❑STEEL G PVC ❑ OTHER d0 <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS [3 HOSE ❑PIPE <br /> _0 SOIL BORING IS PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes a No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION <br /> Laa.Ar sews.oma❑❑HAND AUGER GROUT SPECIFICATIONS <br /> _G OTHERit`^0 '14M'tERMTHER: APPROX.BORING DEPTH Z-6' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> 1 <br /> COMMENTS: <br /> CONDUCTOR CASING❑No C3Yes:Casing da: Casing Depth:.Spring Dia:_ 7t <br /> li <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY z <br /> #OF WELL(S)TO SE DESTROYEt7 ❑OVER-BORE DIAMETER of INCHES TO DEPTH OF FT n <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH CF FT BELOW SURFACE E <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT eELow SURFACE <br /> TREMIE 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 1 have prepared this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,--WA <br /> and all applicable California laws. <br /> ' <br /> Signed �y Title/Company 4u./6 - — M-ktdlt�.i T t1r.J000r�c.S <br /> Print Nam, U )ll rL•+L r.a il.l}-CL� Date b <br /> _ DEPARTMENT USE ONL <br /> SITE MAP IN UNIT V FILE-SITE ADDRESS <br /> WORK PLAN DATED /3 <br /> APPLICATION ACCEPTED BY � V1 ILta!a DATE II �/��������� <br /> GROUT INSPECTION BY FINAL INSPECTION BY 1 1 DATE /-/7-/'j <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 RO# INVOICE <br /> q/ REQUEST PR <br /> O E 125 X 3y�-lo ��� -( SR# 46 3 tp# <br /> t) <br /> VoIl RO# <br /> 3500 <br /> X107. �5ROO 6434 <br /> C-57��WC I� WAIVER ob/;J= C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _�GENCROACHMENT DOC r <br /> EHD 29-01 SM9112 ( WELL PERMIT APP <br />