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°oaulfr. ° SAN JOAQUIN COt1NTY OR <br /> I I L L <br /> ,e: .< ENIRONMENTAL HEALTH DEPARTMtNT SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sictov.orq/ehd <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS UBE6 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 <br /> pof/Ithe San Joaquin County Environmental Health Department. r` <br /> Site Location 76 V 41G/�CAI�.Cross Street R VA-94 Ry• City iToGKTOA✓ Zip�L APN 7 <br /> w&0wner C.O*tWjPN11_1✓AS Address A BVAP61�W City 1&1AAAFAM zip 9581 fI Phone(y 0519-7`33 <br /> C-57 Contractor GcXI&J� Address So /D� � • CIty <br /> /`1 R7 /EZ Lic 51& Phone <br /> Consults Sub Cntr ATG Address ZS 1:V?4&/1A 61R. City Lic Phone&O-S2 f"- 17 <br /> Billable Party ATG FOR GOP Address 75 4YOW/4 G/R. Cit �5�Zip*15S Phone( Y96-IZ/7 <br /> GIS Coordinates:X 3 $• 01,11f Y _/2/• 3Z y <br /> CON TRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEQ PROBE,HYDROPUNCH,HAND-AUGER,OTHERL <br /> I- SOIL BORING IDs 56--1 - uocCOw-STEM 4v6�( <br /> 6- ®WELL IDs_t1W- TO Al W- 7_7- <br /> OTHER <br /> 2OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 6-IrMONITORING ❑HOLLOW STEM DIA OF BOREHOLE <br /> ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: M <br /> _❑EXTRACTION Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS L I/O TYPE OF CASING: ❑STEEL JVPVC ❑ OTHER �� <br /> ._L]SOIL VAPOR PROBE El MUD ROTARY DEPTH OF GROUT SEAL o ' TREMIE TYPE TO BE USED: El AUGERS El HOSE PIPE 1`4 <br /> 1k SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:5q Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e Air Soarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS 4CEA1E—'T 690yT <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH t-BOLTED TRAFFIC BOX OR ❑STOVE PIP <br /> CONDUCTOR CASING XNo❑Yes:Casing Dia: Casing Depth Boring Dia: <br /> COMMENTS: ►✓ 14" -M 60 ` <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 this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all applicable California laws. <br /> Signed �1-� Title/Company /�• r nDJ�� �'�96 ATG A55oG/fjT�s <br /> Print Name Date /2 A3117 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS ]V7— <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE I - =-==AR A <br /> GROUT INSPECTION BY FINAL INSPECTION BY =am=== E <br /> DESTRUCTION INSPECTION BY DATE <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 /> 50 $1212-x _(p �. / /,. SR#& <br /> �j D-> 5 1tM 3 5. �f o �� (/�"" �J 3 00 VI <br /> iso S�3 t z 5 # Ole 2?v <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 WELL PERMIT APP <br />