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SAN JOAQUIN COUNTY RECL6INAL <br /> ENVIRONMENTAL HEALTH DEPARTMENT SEP 02 2014LOP <br /> ip <br /> SITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton. CA 95205-6232 UNI Telephone:(209) 468-3147 Fax:(209)468-3433 Web:www.s WELL & BORING PERMIT APPLICATION PERMITISERVICES <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> App/cation s 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 TRIO,Chapter 9-1115.3.and the Standards of the San Joaquin County Environmental0enHealth Department <br /> Site Location U'r l'1 C 5T¢EET Cross Street F4L$E�T ST. CtyiState 0.747 ZID�— APN IS3-�0-08 <br /> Property 50RAL OIL LLC Po EDK 6tto65 CityiState "F ZI °15161 Phorw <br /> Owner Address <br /> W61 C M <br /> Gb7porltraNtor6A5hDE DRILUNCr Address ZQ� DVI,ASfT'I ST. CityiSlate LIC 1138110 Phone(�Ib) 403-�3 <br /> ConsultantlSu��ybyvC�4���ntr-C Address i�- ctyistate ` Lie _Phone(1410)30M-343Z <br /> Bitable Parry nrrl—,L P�KoeD-urC�f's t>S 11Address CiryiSlate Zip 56 Phone ' <br /> GISCooedinates:X37. 55D-1 Y ' Ljt'.25IV4( <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,MAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 171 MONITORING Cl HOLLOW STEM DIA.OF BOREHOI F ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _J3 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑RPE <br /> _❑SOL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:13 Yes O No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> Q INJECTION es.Air smrm.Dane)❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX BORING DEPTH O BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes.Casing Dia: Casing Depth:,_. Boring Dia:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL T T AEEW <br /> _tU #OFWEL1(S)TOBE DESTROYED JK OVER-BORE DIAMETER OF -10 INCHES TO DEPTH OF6 5 Fr <br /> WFr 1 Ips: (�f VW4 PLhN PRESSURE GROUT TO DEPTH OF_& 60 Fr BELOW SURFACE <br /> GROAT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:0 AUGER$�` HOSE PIPE PS MUSHROOM CAP AT(>3 FT) T -FT BELOW SURFACE <br /> COMMENTS Pl A-N 1'e�R DET ILS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prod-this application and that the work Will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulatiorls, n all ap JiceM Calif nia laws. <br /> Signed j r&vcampary CeOLO(-AST- CSA <br /> Pmt Nene R %-C-T FL&(C) Date ( DI <br /> DEPARTMENT USE ONLY �qJ <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS ` RN"+O/✓ ST 5�'Cr`^" <br /> WORK PLAN DATED u T 1 , <br /> ERM V-TF-D <br /> APPLICATION ACCEPTED BY •yQR•Xw.r� DATE IS ED aWP- AREA <br /> GROUT INSPECTION BY FINAL I'r.,,�y.�,,r/�L�,.TI N BY DATE I'af,�— <br /> DESTRUCTION INSPECTION BY DATE "J �gi� <br /> W. T— <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC A <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'O BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 02 sl3oxu0 70G,P Q Z'/Y sR# 7o?68 <br /> 35-03 o s o0 <br /> PR# <br /> 2900 <br /> C-57 t/ WC_�LWAIVER -C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC AIA <br /> END 2" 711N14 WELL PERMIT APP <br />