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PA IN SAN JOAQUIN COUNTY <br /> ENVYONMENTAL HEALTH DEPARTMRT LOP <br /> 1.1-0T. E.MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3454 Fax: (209) 468-3433 Web: www-siamorn glehd <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 :'�''-11""I.lL,.,,1"i,C� Irtt"....,., <br /> � <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made <br /> Joaquin Countyt. <br /> �De <br /> .glopment Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Departmen <br /> 0 <br /> Site LocatloTt!!�Eas95210 t Hammer La ss Street Kathleen Lane City Stockton zip APN 094-030-43 <br /> is Prolper%q cent. only store Corp. Box 35547 City Tulsa, OK Zip 74 1.5 3 Phone <br /> Owner Address P-0- C-57-6483SJb (916) 363-9395 <br /> All Well Abandonment Address 9245 Beatty Dr CitySacraraentO Lic 'hone <br /> C-67 Contractor <br /> ConsultantISubCntrHorizon EnvironmentaAddreSS4970 WinLlay Drive #5 CityEj Dorado HillsLic_P.hone (916) 93972170 <br /> (S59) 583-3231 <br /> Billable Party Ultramar Inc . AddressG85 W. Third Street CityHjnford Zip 93230 Phone — <br /> GIS Codrdinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> n NEW WELLJBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> El SOIL BORING IDs <br /> 0 WELL IDs <br /> El OTHER IDs <br /> TYPEAt#OF WELUBORING INSTALLATION TYPE CONSTRUCTION-SPECIFICATIONS <br /> _E1 MONITORING [I HOLLOW STEM DIA.OF BOREHOLE [I MULTIPLE I CASINGS El MULTI-LEVEL WELL CASING DIA: <br /> —0 EXTRACTION:Vapor/Water 0 HAmMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL ❑PVC 0 OTHER <br /> _O SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL 'rREMIE TYPE TO BE USED: El AUGERS 0 HOSE El PIPE <br /> [I SOIL BORING 0 PUSH POINT(GPI CPT) GROUT SEAL PUMPED: 0 Yes El No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION(i.e.Air Spsnge_Ozone)0 HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: [I OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX -011 C1 STOVE PIPE <br /> CONDUCTOR CASING El No O.Yes:Casing[)is:_Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE., OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: �Kgl_!_THAT APPLY) <br /> #OF WELL(S)TO BE DERWYT, OVER-BORE DIAMETERINCHES TO DEPTH OF 5 FF <br /> 75 <br /> WELL IDs: EkPRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Neat-cement C]EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE U§EI5, El AUGERS E]HOSE (a PIPE EtMUSHROOMCAP AT L>3 FT) 4 FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I Pave prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all Ahplicable California Laws. XVI1k4ltVWk[gig diko-Fi-A e0 <br /> Title/Compan <br /> Signed <br /> Print Name Date. <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS Z1=1 <br /> WORK PLAN DATED <br /> APPLICATION ACCE EDB DATE ISSUED AREA <br /> GROUT INSPECTfO FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC <br /> PE CODES FEE INFO ANT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST I PR 9 <br /> $125 x 20-02 L SR# <br /> ((O3500)0000070 <br /> PR# <br /> (2900) <br /> C-57 WC WAIVER __1___1 _C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />