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��'"`'''("�•� SAN JOAQUIN COUNTY FILE COPY <br /> I. �.F•.P <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> e <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone:(209) 468-3147 Fax:(209) 468-3433 Web:www.sigoy.orQ/eh UNIT IV <br /> /ROS <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 54? E. Grrcw'F Li k-L ed Cross Street 4). IA-z 1fl6- y^, City/State Ir'.u.,,',CA Zip 453'f6 APNPropert .25o of tz003' <br /> Owner-y�l 21 69 -S✓f C�c'�`'�- V <br /> Owner 7aGl r� Address Cv N.�� City/State phone9.25-41(5.63757 <br /> C-57Contractor Fat co'? E7411iu Address.22o N.ca5f SF. City/Statek?oA64CA Lic 9,Y,599 Phone 930-6k,f-36co <br /> Consultant/Sub Cntrntr F60-5c; Addressa1;21 N rtCity/State`t'1v �G4d Lic Phone 915-YYI-3�3� <br /> Billable Party '-Y3cn5 Address ICity/State �' Zip 94/15"y6 Phone r' <br /> GIS Coordinates:X -T471 Y fzC�IIG3 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER) <br /> El SOIL <br /> SOIL BORING IDs /�' <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OFCASING: 0 STEEL ❑PVC 0 OTHER <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> _0 SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION lie.All Saaroa.Oz.. El HAND AUGER GROUT SPECIFICATIONS <br /> -0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth:_Boring Ola:_ <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THATAPPLv g•I., <br /> #OFWELLS)TOB� DEBTRppYED OVER-BOREDIAMETER OF /o INCHES TO DEPTH OFJ,�FT <br /> WELL IDs: -I TI�r..�(•h EP-- ❑PRESSURE GROUT TO DEPTH DF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS 11 y e el4 n, " u ❑EXPLOSIVES FROM To Fr BELOW SURFACE <br /> TREMIE TYPE TO BE USEpp:($AUGERS LJ HOSE PIPE ❑Mj1SHROOjv1 C A L3.FT) FT BELOW SURFACE <br /> COMMENTS Sae 4'I{ot Gtr.c. pT-S�-w,Prev work P(nw< '7�a�le I I-or Well <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulatl pvamd all ap IcabJE'galif6rn( laws. y <br /> Signed '�'^-"� '��� Title/Company C�P.0 6-'fR(VyJ <br /> Print Name K. 'Cy Icl Soz" I(� Date l`{l1� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 522 E, GR9NTA AlC- RonD 72z4QN <br /> WORK PLAN DATED OVErn S 2.oiy ' <br /> APPLICATION ACCEPTED BY 4. yol4ru.-I DATE I <br /> GROUT INSPECTION BY FINAL INSPECTION BY E/ -J -zy <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: qFAID# j4FFAC# <br /> PE CODES FEE INFECVD BY DATE SERVICE RO# INVOICE <br /> REQUEST PR#2LU Z $1302 �UC(�PE2 t(/z / SR# 7779 <br /> 2403 310 RO# <br /> (3500) <br /> PR# <br /> 2900 <br /> C-57 / WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOC /t/ <br /> EHD 29-01 7/24/14 WELL PERMI APP <br />