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• • <br /> f CLUJ C 0 Y <br /> SAN JOAQUIN COUNTY <br /> zryy—�� 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.orglehd 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 andtor 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 /> Live Oak Road 95240 061-160-02 <br /> Stte Location 11818 N. Furry Rd Cross street _ _ Ciry/Slate Lodi.CA zip APN <br /> P�erty Kurt and Sandra Kautz Address 5490 Bear Creek Road City/Sista Lodi,CA Zip 95240 Phone (209)368-3113 <br /> C-57 Contractor Woodward Drilling Address PO Box 336 City/Stale RluUiva.CA Lic 710079 Phone (707)3744300 <br /> Consultam/SulaCnlr Fall Creeek Enor Address PO Box 7834 City/Stale senor Caq CA Lic 55605 Ply (831)426-1440 <br /> Billable Party Bear Creek Winery Address 11900 N Furry Road City/State Lodi,CA Lp 95240 Pie (209)368-3113 <br /> GIS Coordinates:X Y <br /> CO TRUC WORK T BE PERFORMED: <br /> NEW WELLIBORMG(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDS <br /> ®WELL IDS MW-7D <br /> I]OTHER IDs <br /> TYPE 6#OF WELLJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> —J&MONITORING G HOLLOW STEM DIA OF BOREHOLE B Inch E3 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA 22 inCh <br /> _O EXTRACTION:Vapod Water 0HAMMER/ORIVEN CASING THICKNESS SCh 40 TYPE OF CASING: [3 STEEL In PVC ❑ OTHER <br /> ____O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 95 TREMIE TYPE TO BE USED: 91 AUGERS ❑HOSE ❑PIPE <br /> _0 SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:W Yea ❑No(MAXIMUM FREE FALL DEPTH IS 90 Fr) <br /> _p INJECTK)N I'•AnSy e )❑HAND AUGER GROUT SPECIFICATIONS Neat Cement <br /> _[]OTHER: ❑OTHER: APPROX BORING DEPTH 128 feet D BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING C4 No❑Yes:Casing Dia:__Caning 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 THAT APPLY) <br /> OFWELL(S)TOBE DESTROYED ❑OVER-BORE DIAMETER OF_INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM ro FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERS HOSE PIPE ❑MUSHROOM CAP AT Q3 FT) FT BELOW SURFACE <br /> ._.__ ._.._COMMENTS _..._. <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby realty that I have prepared this application and that the work will be done In accordanea with San Joaquin County Ordlnanbee,Rules and <br /> Regulations,and all appl/# b1 IH c`rnianla(IW�s.,r C(Vr�1 (,^,, nn,� / 1— �A <br /> Signed k"'°t-��� Title/Company I 't, tri7Y�' tr1X-�' / -�( l/V 1Jn <br /> Print Name F�D .1/ 1 C/ f 4 -I q <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTWCONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEEINFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE ROO INVOICE <br /> REQUEST PRO <br /> 21() x U 3R# O <br /> RO# <br /> _ 3500 <br /> PRO <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> ENO 29-01 51OW12 WELL PERMIT APP <br />