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opg!'.IN„ SAN JOAQUIN COUNTY r./ R E CO• Y <br /> ENVIRONMENTAL HEALTH DEPARTMENT OCT i i—ZU16Op — <br /> :4!�. 1868 Hazelton Avenue, Stockton, CA 95205-6232 N SITE MITIGATION <br /> q•.;FoN�P Telephone: (209)468-3147 Fax:(209) 468-3433 Web:www.s' o1Vtn' T/SERVICES tw <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/9I-1115.3,and the Standards of the San Joaquin County Environmental Health y gnt. c/ <br /> Site Location hi 6�".lafdh D f a J</4LCmss Street-1 U `t r A e r City/State LD zip, APN 011-M 0'D / <br /> Property ''ii <br /> Owner S�f{e ro,Me W V,p r- I) <br /> / Address •D. Ux 7_49 city/state Zip YS Z'l Phone 963-3/0`f <br /> C-57 Contractor W 00 d w r Address Sso tai\J ! d City/state Lio 0 Phone 707-317y-YSOO <br /> Consultant/sub-Gntf Ja, Address 363 z— 5-t_ 5iet 300S city/state 56-A Fran Lic Phone `fIS-ZY313-0' <br /> Billable Party n¢ -).a , Address City/State 5A Ale Zip 4({IO Phone 54 Az L <br /> GISCoordtnates:X62`I571ZH Y 2.�4 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> M NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> SOIL BORING IDs _-Z f� <br /> WELLIDs� t.J- 19I Gf�7W-7_ti W-7.Z <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �❑MONITORING ®,HOLLOW STEM DIA.OF BOREHOLE 8' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS SC-� L(o TYPE OF CASING: ❑STEEL EJPVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL—L­r�;_) TREMIE TYPE TO BE USED: GAUGERS ❑HOSE ❑PIPE <br /> 1®SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION(i.e Ar soame.Owe)❑HAND AUGER GROUT SPECIFICATIONS A)Pli-t� Ce IM en t <br /> —❑OTHER: ❑OTHER: APPROX.BORING DEPTH 70 ❑BOLTED TRAFFIC BOX OR W STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING CANo❑Yes:Casing Dia: Casing Depth: Boring Dia: <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 BE 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(>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 thisapplicationapplication and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations, all a licable Ca iforn' layrs„ � / <br /> Signed ,/ ui� miry/�G �y✓/J / Title/Comp any LSO O i S L'L <br /> Print Name _ )� .L�a-.oX d�CE.fvcl Date I C/ <br /> L <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 1,84S62 n/ t 19 U 8 $ LJW Rd. 4ob/ <br /> WORK PLAN DATED SC PTE / <br /> APPLICATION ACCEPTED BY 1. YO r Krc DAT I AREA16'?Q <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE /I�►-f <br /> DESTRUCTION INSPECTION B y <br /> DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SER. <br /> VICE RO <br /> REUES <br /> T PR:• INVOICE <br /> $125z std 137`l 7e6 /0-11-1 SR# (t8 ST) <br /> )�9 0 3 3?S 3 75 14vo /3 3 RO# <br /> 3500 / p? <br /> �-lt;U S 25- ZY 29o0 CPCJ J J� <br /> C-57 f/ WC _(,WAIVER VWC-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC i ' <br /> EHD 29-01 5109/12 WELL PERMIT APP <br />