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• • FILE COPY <br /> a Pmt, o SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT -L0 P <br /> ` SITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> ..a <br /> P Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.s'gov.org/ehd <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 Z'(SS6 pl�'^�h ross Street W 5c-""'+V- Rd City/SF1tte"Y/C4 Zip Qs377 APN ZA4-22o-O�o <br /> Owner <br /> Property <br /> PI.,11w5 so"�O. Address /7ZSyW�ta stew. ltY/StBte� /ems Zip 95377 PhonjZoJL 33-5-381 ^! <br /> Eg -'rs.w. n ire) oc. 011 T�+iG two./MfS /'fir. h, '4 S C 95- 70 B f "Z-8179 <br /> C-57�otractor Addres Ci /Sta a LiLG e/ Phont' 3 ) <br /> Cer�(� G -L, f eve y o u- Aca �+soos. pe..,. t 43V - <br /> /5g`y1�aYnte/�5b (/pt�� Address - .4e ;'V- city/State 4 Phon69zS)y48-criz <br /> Billdbla Pa L' N' &"4 51dress S'C"*R City/State Zip­-!&^"s'- Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPR BE,TYIDROPUNCH,HAN AUGER,OTHER) ?. <br /> SOIL BORING IDs Sha/e b>.%ays ,) Al Al4 rel DS; E�-EZ /// yz RU-I -�o SV-�y K <br /> Ll WELL IDs -20 wa,.Pk <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 5 <br /> _❑MONITORING 0 HOLLOW STEM DIA OF BOREHOLE ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vaporl Water 0 HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> _❑SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> _IRSOIL BORING R1 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _D INJECTION(I a Nr Soame Ozone)0 HAND AUGER GROUT SPECIFICATIONS <br /> _O OTHER: 0 OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR 0 STOVEPIPE fE <br /> CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth:_ Boring DIs: <br /> COMMENTS: <br /> f <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO SE 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 TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS <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 /> Regulations,a all a plicabli9 California laws/ �� <br /> Signed /e'�'� Q-�f4"'"'�` Title/Company �V• 1 L PI'rL {' GIVEN 1/`�^ t"7 ` <br /> Print Name l0 /- I Date S G ! t <br /> r� ('r DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 'A' ]50 l7 ArU SAN /c 1' <br /> WORK PLAN DATED V1441 20r2o(I f <br /> APPLICATION ACCEPTED BY J•1�D 19-ICum DATE IS /G <br /> GROUT INSPECTION BY FINAL INSPECTION BY CKAKU4q DATE 6-64 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMTREMITTED CHECK# RECV'D BY DATE SERVICE I Ro# INVOICE <br /> REQUEST PR# <br /> 90S $125X r z5 3vvGr �U6.wTLQ 5-2/47 SR# 7- <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 1L WC �LWAIVERW C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 2"1 5/09/12 WE]L PERMIT APP <br />