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• • f ILE,PflPY <br /> SK T-1-D SAN JOAQUIN COUNTY <br /> c "r ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Haze@on Avenue,Stockton, CA 95205-6232 SITE MITIGATION <br /> A Telephone:(209)468-3147 Fax:(209)468-3433 Web:www.siaov.orQ/ehd UNIT IV <br /> k <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 Cc"Environmental Health Department. <br /> Site Loeatlon 6111 E Armstrong Road Cross Street Furry Cllyistate Lodi,CA Zlp 95240 APN 051-140.54 <br /> Property Kurt and Sandra Kautz Address 6490 Bear Creek Road CllyBtate Lodi,CA Zip 95240 Phone (209)388.3113 <br /> C-57 Contractor Woodward Drilling Address PO Box 336 Cityts a(e Rf,Vm.,CA U, 710079 phone (707)374-4300 <br /> ConsuhanUSub Cntr Fall Creeek Enar Address PO Box 7834 CIVState Sana Cn¢CA Lie 55605 Phone (831)426-1440 <br /> Billable Parry Bear Creek Winery Address 11900 N Furry Road City/State Lodi,CA Zip 95240 Phone (209)368-3113 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ®NEW WELUTS ING(CPT,GEOPROSE,HYDROPUNCH.HAND-AUGER,OTHER) <br /> 0 SOIL BORING Ins <br /> ®WELL IDs_MflP�i�"- <br /> 0 OTHER IDS <br /> TYPE&S OF WELLBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING M HOLLOW STEM DIA OF BOREHOLE B InCh 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2 inch <br /> _0 EXTRACTION:Vaporl Water 0 HAMMEPJDRIVEN CASING THICKNESS SCh 40 TYPE OF CASING: 0 STEEL 19 PVC 0 OTHER <br /> _0 SOIL VAPOR PROBE O MUD ROTARY DEPTH OF GROUT SEAL 95 TREMIE TYPE TO BE USED:ISI AUGERS 0 HOSE 0 PIPE <br /> —0 SOIL BORING 0 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:®Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION m,..h,Soar,,.Oao fl HAND AUGER GROUT SPECIFICATIONS Neat cement <br /> __0 OTHER: 0 OTHER: APPROX.BORING DEPTH 120 feet 0 BOLTED TRAFFIC BOX OR W STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING 14 No 0 Yes:Casing Dia:__Casing Depth:_Bonng Dia:_ <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: oESTRucTION METHOD•tcHE KALL THATAPPLYI <br /> #OF WELL(S)To BE DESTROYED L]OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: Q PRESSURE GROUT To DEPTH OF 100flet FTBELOWSURFACE <br /> GROUT SPECIFICATIONS OEXPLOSIVES mom TO FTBELOWSURFACE <br /> TREMIE TYPE TO BE USED:0 AUGERS 0 HOSE (7 PIPE ❑MUSHROOM CAP AT p_3FT) FTBELowsURFAcE <br /> COMMENTS ..._ <br /> 6 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that Use work will be done In accordance with Sen Joaquin County Ordinances,Rites and <br /> Regulations,and all ap i Is IfforAlla laws. <br /> Signed C� 7tlelCompany Civil Engineer/Fall Creek Engineering <br /> Print Name Frederick A.Yukio Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE•SITE ADDRESS <br /> WORK PLAN DATED we <br /> APPLICATION ACCEPTED BY DATE I <br /> GROUT INSPECTION BY FINAL INSPECTION BY lavile <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO ANT REMITTED CHECK# RECV'D BY DATE SERVI PRO# INVOICE <br /> r1 REQUEST PR i <br /> f S x SR# () 4'( Z- <br /> 7 ROS <br /> Il 3500 <br /> PR# <br /> ]900 <br /> C47 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 20-01 5!09112 WELL PERMITAPP <br />