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1 <br /> • SAN JOAQUIN COUNTY *FILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 East Hazelton Avenue,Stockton,CA 95205-6232 SITE MITIGATION <br /> ' Telephone:(209)468-3464 Fax:(209)468-3433 Web:www.siaov.org/ohd UNIT IV <br /> SFO <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 Consruct 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 /> She Location 26 ZSo Nrds—l"r: Bross Street 5lcek/-0n ST. City 7AornTorl Zip X68 APN 4501-13D-09 <br /> Prupe1tyAndrew Johnson 3060 Calle Bonita Santa Ynez CA 93460 714-334-9414 <br /> Owner Address City Zip Phone <br /> C-57Contractor Prra ,-c Address 17-19 /4114 $l-SwUi A City Wvo,41 +4 Lie 90 G849 Phone530 60-36x+ <br /> ConsuHantfSub Cntr Od,c, '&-1"4 l-14dress City n 9Jy Lie Phone 213-380-d2fo <br /> Billable Party Address H City 11 Zip /0 Phone H <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE <br /> EWELUBORING(CPT,GEOPROBE,HYOROPUN <br /> V /CH,HAND-AUGER,OTHER) <br /> Q 501E BORING IDs 5(3/r S62r 563r St34 <br /> 0 WELL IDs <br /> 0 OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATIONTYPECONSTRUCTION SPECIFICATIONS <br /> _Q MONITORING 0 HOLLOW STEM DIA OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTk EVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor!Water 0 HAMMER DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROIJr SEAL TREMIE TYPE TO BE USED: 0 ANGERS 0 HOSE 0 PIPE <br /> I,�ErSOIL BORING ff 1USH POM ON CPT) GROUT SEAL PUMPED:0 Yn 9f No(MAXIMUM FREE FALL DEPTH IS 30 Ff) <br /> _O INJECTION(e ArSo .oene10 KAM AUra3t GROUT SPECIFICATIONS 8< ren.(!511 <br /> 1rn� <br /> _O OTHER: 0 OTH9t�APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING I(No 0 Yea:Casing Cls:_Casing Depth:_Boring Dic_ <br /> COMMEIITS: I3 01� t".if lar �'cc*B Af+d r, u+r nj Sy <br /> NOTE: OFFSITE WELLS i BORWGIS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALLTHATAPPLYI <br /> _#OFWFLL(S)TOBE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF Fr <br /> WELL IDs: 0 PRESSURE GROUT TO DEFrH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS 0 EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS 0 ROSE PIPE 0 MUSHROOM CAP AT L>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORIUNG DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> 1 hereby certify drat I have prepared this applicaboo and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and&I cable California Lawn. <br /> Signed \ Title/Company Project Manager Odic Environmental <br /> Prim Name John Winkler Date 2 / <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESSI U /�'/ )ccn riarJ 5't TIYo,I� r.>A!� <br /> WORK PLAN DATED JsJ Ive j 2t>/ 3 j:=jj f= 'Q— <br /> APPLICATION ACCEPTED BY I . G/oY4' uM DATE IS.__ - <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FACT <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> 7 REQUEST '/PR E <br /> $125 x I /Z{�, 1 S 2- d-r�avTF!! I-I-I SR# 7�! 7 7 <br /> RO# <br /> Qv 3 37-T (asoo <br /> PR# <br /> 2900 <br /> C-57 ✓ WC ✓ WAIVER A/ C57 LETTER OF AUTHORIZATION TO SIGN PERMIT v ENCROACHMENT DOC <br />