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uv if .. C SAN JOAQUM COUNTY <br /> r`r'~ ENONMENTAL HEALTH OEPARTMT LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> Telephone: 209 41a6-3454 Fax: 209 465-3433 Web: www.s• ov.oa Ith UNIT I!/ <br /> caCiFOR � p ) 4, } <br /> WELL & BORING PERMIT APPLICATION <br /> i <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 Sari <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County.Environmentai Health Department. <br /> Site Location 1210 East Hammer Lar&oss Street Kathleen Lane City Stockton Zip 95210 APN 09:4' 03h0L]-2 <br /> Propertrbadral2 Hammer Lane LP 50 Tice $1vd. Woodcli€f Lake 07675 (323)938-0969 <br /> Owner Address City Zip Phone <br /> C-57Contractor All Well Abandonm%�mSS9245 Beatty Dr. Ste A CitySacramen.to LicC-57-84835-�)hone {916}363-9355 <br /> Horizon Environments 4970 Wind la Drive #5_ El Dorado s <br /> ConsultantlSub Cntr kddress P Y' City dHi11Lic Phone (9161 939-2170 <br /> Billable Party Ultramar'. Inc -Address685 W. Third. Street CityHanfard Zip.93230 Phone 559 583-3231 <br /> GIS Coordinates:X Y . <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> 4 TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE . ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING CIA: <br /> _©EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP!CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 Fr) <br /> _❑INJECTION{i.e.Air Soarne.Ozone)E)HAND AUGER GROUT SPECIFICATIONS <br /> _O OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR EI STOVE PIPE <br />{ CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: r - - <br /> NOTE: OFFSITE WELLS & BORINGS REQ IRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY <br /> -2;VW-3; T VW-5: VW-6 <br /> #OF WELLS)TO BE DES <br /> D - OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDS VW-7;V.W-8;SW-1 W-3 MW- •MW-5;MW- -7; /r PRESSURE GROUT TO DEPTH OFmn 1 2 E6.FT BELOW SURFACE <br /> GROUT SPECIFICATIONS - - ❑ EXPLOSIVES FROM To FT BELOW SURFACE <br />} TREMIE TYPE TO BE USED:❑AUGERS CHOSE ETPIPE LaMUSHROOM CAP AT L3 FT) — FT BELOW SURFACE <br /> COMMENTS <br /> f 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby certify thKlappilcable <br /> have prepared this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> f Regulations,and California Laws. p <br /> I SignedTitle/Company [trr3►,Gre�imc �}�{ 1y# 14 � � ' <br /> l Print Name ll. Date O I <br />.I DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS <br /># WORK PLAN DATED <br /> f APPLICATION ACCEPTE BY DATE ISSUED ��J`�D/3_ AREA <br /> GROUT INSPECTION BY _ FINAL INSPECT DATE <br /> DESTRUCTION INSPECTION 13Y DATE r <br /> t 7i <br /> COMMENTS/CONDITIONS: 76 - /��/ /��� `� �{ / o <br /> s ACCOUNTING ONLY: AID# FA'L# <br /> ESERVICE RO# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# INVOICE <br />` sow $ 125 /o' sR# �CA� <br /> RO# <br /> PR# <br /> (2900) <br /> C-57 . WC WAIVER Z------057 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />