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1. ORIGINAL <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232� UNIT IV <br /> Telephone: 209 468.3147 Fax: 209 468-3433 Web:Www.sigov.orA/eh <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 �)32� WO►IE'WO D Cross Street PIC�OLt �O- City/State �� Zip 6IaiS APN 081 -100-11 <br /> Property I�EDWOOG <br /> Owner LO �O� G Address City/State <br /> CIT-r,C,t Zip 114063 Phone <br /> C57Contractor C/45C/4 Address City/State 9A--r--x <br /> Cr+ Li. //U Phone <br /> Consultant/Sub Cntr L Address 1,%, Tl E, ITE Tr�1�� City/State t4 ,C,{� Lic W316 Phone(6116) 88x1.'M 92 <br /> Billable Part CSAtt�ptL I 0 5 <br /> Party PP-oDucTS US ddress ' City/State `' Zip phone <br /> GIS Coordinates:X 37 9'87Z9 Y <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 WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [I 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 ar.e.arSwroe.ozonel❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METIM: CHECK ALL THAT APPLY <br /> #OF W ELL(S)TO BE DESTROYED OVER-BORE DIAMETER OF 10 INCHES TO DEPTH OF F5 FT <br /> WELL IDs: MN-40 ❑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 NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby cert' that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulatio d all ap hfornia laws. !�, <br /> Signed -j X- Title/Company 6, UW&IST/Gt-_4 <br /> Print Name g� Cr�TlOYD Date ��ZS�'LU(y <br /> _DEPARTMENT /USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS Y3�5 1-447Z-kLoo PaeA78.1tJ <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY J•Y2'+Ku VVP DATE I 0 °`AREA /62f <br /> GROUT INSPECTION BY FINAL INSPECTION BY E L311 <br /> DESTRUCTION INSPECTION BY DATEIt <br /> ' <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 /> 332 $130x / 3U� /(7U �pc"vj�iZ - —It�I_3't�l SR# U7 <br /> 3 c563 3ko — RO# <br /> 3500) <br /> PR# <br /> (2900) <br /> C-57_j� WC V ;rVANER N4_. C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOCy <br /> EHD 29-01 7/24/14 WELL PERMIT APP <br />