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o.P4`'''I•N c sAN.JOAQUIN COUNTY FILE <br /> ENPONMENTAL HEALTH DEPARTM NT P <br /> DIV <br /> N'. <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATIONUNIT IV <br /> ;•.. :::.�:P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:wwwsigov.orctlehd <br /> �tFOR <br /> WELL & BORING PERMIT APPLICATION <br /> F,OR WELLSAND 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 So�JO. DV72 W. <br /> �''cross sheet S• Ruartlst\( City TrOfqzip S3 APN Z,S3-Z10 31 <br /> - <br /> PropOwnerty11�Q bray Phone 36.0'165 <br /> Owner�PatVV P. lIJ i�'lt Address �?i0 W• (a.n✓\G City e Zips 537 <br /> C-57 Contractor I?4d.N2Lo(I?_ Address I t.3S Ali of S!.r Sk. A City Woodla.,d Lic Phone Ci 3o 16 3600 <br /> Consultant/Sub Cntr 6N V 1 R 6 kL Address &j)01 SLAE11st6wnd f S1[700 City it Lic 0 Phone 51 0,6 Ss•7AI <br /> Billable Party 1;�eEJV\ (Z0 hl Address " City t` Zip Phone <br /> GIS Coordinates:X �(n3�q/ . L Y / {/SCyy�iU�egg? <br /> CONSTRUCTION WORK TO BE PERFORMED <br /> ❑ NEW WELUBORING(CPT,GEOPRO'+F HYDROPUNCH.HAND-AUGER,OTHER) <br /> SOIL BORING IDS i — S8 of 6W/ - 6-w3 <br /> WELL IDS <br /> ❑ OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING // <br /> HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water O HAMMER/DRIVEN CASING THICKNESS N/4 TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER �( <br /> _❑SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL NIA TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> _?_�(SOIL BORING 56 PUSH POINT GP CPT) GROUT SEAL PUMPED: 0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT), <br /> e <br /> C <br /> _O INJECTION Ii.e.Air Soarae.Omnel[I HAND AUGER GROUT SPECIFICATIONS D E✓+[&" rj LW v{' +✓11Ui L "tZS�r� <br /> —[]OTHER._ 0 OTHER: APPROX.BORING DEPTH IS'10P)lif70°(fiA 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE F <br /> 1_� CONDUCTOR CASING 0 No"A Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS:skAtIOW 16/Of� :b 19' WI 'D= r IQC&"ern T-91> -� 00 C0 %A t '! R$A 4z 70° <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 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 appacation and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulatioy✓ liwbleCalif <br /> Signed z \ CA o nia aw : Title/Comp any <br /> __ r. /��� V/2on/ �itJ71<-ttNiF770NfYL. <br /> Print Name JIe41 W!}LC-4Ll/L- Date62-1e01/Z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS r) � G) l,(rvwE 'l 0, <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY - _ DATE ISS U'J - A <br /> GROUT INSPECTION BY '�� ARE <br /> irY FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE 2-24'(Z <br /> COMMENTS/CONDITIONS <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> a9 D5- $125 X sR# <br /> 0 375 �t375 Roo <br /> pzo3 g <br /> S 2900 S 7,05' <br /> C-57 ✓ WC WAIVER All C57 LETTER OF AUTHORIZATION TO SIGN PERMIT !i ENCROACHMENT DOCS_ <br />