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oA��IN Q SAN JOAQUIN COUNTY <br /> z �`"'— ENVIRONMENTAL HEALTH ®EPARTMNT LOPy <br /> �. a <br /> 600 East Main Street Stockton, CA 95202-3029 1 �i• <br /> I. o <br /> Telephone: 209 468-3454 Fax: 209 466-3433 Web: Www.sigoy.®rc :W JTIV <br /> � d D d D --- <br /> WELL & BORING PERMIT APPLICATION 101 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM GATE 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 witarr <br /> Joaquin Coun> 5 o meat Title,Chapter 9-1115.3,and the Standards bf the San Joaquin.County Environmental Health Department. <br /> East Hammer La Kathleen Lane Stockton. Zi 95210. -0t_ 4`'030'=1] <br /> Site Location rMoss Street City p. APN . <br /> Propertp <br /> Owner Bhadrall Hammet Lane LP Address 50 Tice Sled. City Woodcliff Lake Zip 7675 Phone (323)938-0969 <br /> C-57 Contractor All Well Abandonm hdress9245 Beatty Dr. Ste A City.Sacramento LICC-57-84835$hOne (916)363-9355 <br /> Horizon Environmenea E1 Dorado s <br /> Consultantl5ub Cntr kddress4970 Windplay Drive #5� City dHillLic Phone (916) 939-2176 <br /> Billable Party Ultramar Inc •AddresS685 W. Third Street CitYH anford Zip 93230 Phone 559 583-3231 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL fDs <br /> ❑OTHER IDS <br /> TYPE 8#OF WELL/BORING 'INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> r„_❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL.WELL CASING DIA: <br /> _O EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑FVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT.SEAL TREMIE TYPE TO BE USED: p AUGERS ❑HOSE ©PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:CI Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e Air Saarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> I COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> I DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION MET OD: CHECK ALL THAT APPLY) <br /> 11 OF WELLS)TO BE DESTROYEDMW_9 ❑OVER-BORE DIAMETEROFINCHES TO DEPTH OF FT <br /> WELL 1Ds: _ [ PRESSURE GROUT TO DEPTH OF /U FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:-❑AUGERS IR HOSE ❑PIPE (R MUSHROOM CAP AT(>3 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,and aillApplicable California Laws. , <br /> Signed Title/Company <br /> Print Name b Date w <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS �a%O <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED yDATEISSUED.� 3 AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> I DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> E ACCOUNTING ONLY: : AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO.# INVOICE <br /> REQUEST PR# <br /> J�0oR $125x 1__70570711 ���o/ SR# <br /> RO# <br /> (3500)0000670 <br /> PR# <br /> C-57 WC _WAIVER -. ' C57 LETTER OF AUTHORIZATION TO SIGN PERMIT - ____--ENCROACHMENT DOC <br />