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, � <br /> �t � ORIGINAL <br /> �6 <br /> SAN JOAQUIN COUNTY <br /> 2` �r ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> -� 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> .. a:P Telephone: (209)468-3147 Fax:(209)468-3433 Web:wwwsiyov.orcl/ehd <br /> �lFOR <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 applicatlon is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Enviro mental Health Department. <br /> Site Location 7S Nw �[ Cross Street CA, OtiYe City/State 5t��h Zip APN 1-71-21-03 <br /> Propertyn / p ,{ t5 0 �/ <br /> OwerK t t7 Address go- a _P /t V'• City/State Zip 9 356 Phone �lq& y'77X7 <br /> C-57 Contractor t Address 1n3� / eIym � r[le City/State Cay%b�ALic 1&110 Phone 9l6.6o3S. 11(�? <br /> ConsultanVSub Cntr Address 950 �i/A h &,VP ��u�1°/2.?City/State 15",CA Lic Phone ?/Z.. 100S.2Dw <br /> Billable Party Address City/State Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION Ce.AirSoarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> 7 DESTRUCTION WORK TO BE PERFORMED: �(,({t/- DESTRUCTION METHOD: CHECK ALL THAT APPLY -r� <br /> #OF WELL(S)TO BE DESTROYED OVER-BORE DIAMETER of 0 INCHES TO DEPTH OF 0.I FT <br /> WELL IDs: M/— N/` W- W--� - l� PRESSURE GROUT T D PjH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS — i EXPLOSIVES FROM W TO J(J FT BELOW SURFACE/Yf � <br /> TREMIE TYPE TO BE USED: AUGERS ❑HOS PIP ,y MUSHROOM CAP AT L3 FT)____.,5 FT BELOW SURFACE <br /> COMMENTS r C /� hihi� <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I havglflepared this ap lication and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all ap9K5able California 1 �/ �I <br /> Signed Title/Company tifrf!/LlO�tAk�N�f C4�- <br /> Print Name e4lne✓n,.' G4 Oyp"" Date dt <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED DATE <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE ' (0-1 <br /> COMMENTS/CONDITIONS:�� O <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RID# INVOICE <br /> -7 REQUE/ST PR# <br /> Z $125 x,- ���� 3 -3--7 SR# <br /> 00 5­24-3,-7 /.f� 3 00 <br /> PR# <br /> 2300) <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 5 009/12 WELL PERMIT APP <br />