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SAN JOAQUIN COUNTY 0 R <br /> o .- <br /> = ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1 <br /> 1868 Hazelton Avenue; Stockton, CA 95205-6232 <br /> SITE MITIGATION <br /> 7! <br /> i :?f Telephone; (209)468-3147 Fax:(209) 468-3433 Web:www.sigov.orq/eh UNIT IV <br /> \ ,KEJ6 <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 `1315 �� cross street FICC(x4 city/state S'�OCK N zip a[SZ1S APN b� -ICO-3y <br /> Property <br /> Owner_j3FV LNyEgM N-6 LNG. Address LI3lS E V,/ATE-?-WO 9-0 �°r` X5215 <br /> City/State C�4 Zip Phone <br /> C-57 Contractor Q IM 41)1- Address _ City/State t�� Lic //O Phone <br /> Consuttant/Sub Cntr CPQ! Address tcq6q 1 �i�jp� City/StateCo'R�r/,�,c,�. Lic X55 91-f- Phone <br /> Billable Party S��D � P WcTsyS I d5dress " City/State `' Zip 9s��U Phone <br /> GIS Coordinates:X32, 7 7 Y —/2-/• 2Y7.z(� <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBF,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _O 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(iP-Airsparge ozone)❑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: D STRUCTION METHOD: CHECK ALL THAT APPLY <br /> #OF WE L(S)TO BE ESTROYED OVER-BORE DIAMETER OF T-t 0 INCHES TO DEPTH OF 72-61T FT <br /> LL <br /> W IDs: I'iw -4- �royjVi MW-'[ .4 PRESSURE GROUT TO DEPTH OF -5- /2 FT RFI OW SURFACF <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:CKAUGERS ❑HOSE Pj PIPE MUSHROOM CAP AT(>3 1=T) 3 FT BELOW SURFACE <br /> COMMENTS Slf WOVT� ?L-+r--I FaR DETAILS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> he <br /> that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulati ns - Title/Company &EOU0y d1 ati ap b itfornia laws. <br /> Signed ISTAVA <br /> Print Name �j�lp TLo�i� Date <br /> _DEPARTMENT USE ONLY <br /> SITE PAAP IN UNIT N FILE-SITE ADDRESS_ /5 W V+7�Q L� P40'J-57ZQ'K7b4) <br /> WORK PLAN DATED J Ct wE /Co 1 <br /> APPLICATION ACCEPTED BY J• Y0 19 Kut +1/1 DATE I ytED '1 _ --.,.AAEA /` <br /> GROUT INSPECTION BY FINAL INSPECTION BY OIJ DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CON D ITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV D BY DATE SERVICE RO# INVOICE <br /> q REQUEST I PR# <br /> �O2 $130 x 9 f (?oa/v)-ER- SR# <br /> 3s�� 3 is) RO# <br /> (3500) <br /> PR# <br /> (2900 <br /> C-57 WC WAIVER _ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT 1/ ENCROACHMENT DOC <br /> EHD 29-01 7124774 WELL PERMIT ADP <br />