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,: ! RECEIVED � '�'���`� ��;.. :10� . ' �' �J U �•cRl! <br /> eq�ly JUN 2 3 2014 SAN JOAQUIN COUNTY <br /> <.. <br /> �OpOU1N COUtJVIRONMENTAL HEALTH DEPARTMENT TA SITE MITIGATION <br /> �.: EAINIViRUEFARTM TF3Ii8 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> E <br /> d:,1au1 `p Telephone:(209) 468-3147 Fax: (209) 468-3433 Web:www.siaov.ora/ehd <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 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location4Y 1V�• O I• O 1 tJ� Cross Street ii4--SS City/State Zip 3 7? APN Ja`j It DO <br /> Property "7<�l j-D V c2c t Ci /State KCL i G13/7 Phone LJ�i-`b.�6-U67� <br /> Owner (Y1 JSw OI �C— C� Address l City/State <br /> C-57Contractor V cJ Address "?� � tom. J�-b-t�k- t7:'. City/StateLic Phone tv'i •N44-7700 <br /> ConsultantlSub Cntr -J w Address City/State Lic _ Phone <br /> Billable Partyrn.,..,._ nt:..r G;, Address A.3,cn1,, City/State etZip "rS-57 ) Phone �t•`.�36-4Ft`0 <br /> GIS Coordinates:X'0 Io`Si ' 12.Z Y -57`4 1'32 r'• <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL to <br /> ❑OTHER to <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE— O MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION:Vapor/Water ❑HAMMER/DRtVEN 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 fla.Air SpaMe.ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: <br /> OTHER: APPROX.BORING DEPTH -, ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No 0 Yes:Casing Dia: Casing Depth: Boring Dia:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS 8r BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD,(CHECK ALL THAT APPLY) <br /> #OF WELUS)TO BE DESTROYED ®OVER-BORE DIAMETER OF rF? wcHES TO DEPTH OF t7D-17dr <br /> WELL IDs: 7 - S _ El PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONSy 7 [IEXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS [IHOSE ~ PIPE 0 MUSHROOM CAP AT(>3 FT) 1' 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 /> Regul tions,and all applicable <br /> ,California laws. <br /> Signed -r Title/Company� , l Yl✓y�'� 01 <br /> Print Name Date <br /> DEPAR <br /> 1TMENT SE ONLY i ) vA <br /> SITE MAP IN UNIT IV FIL -SITE ADDRESS �� t 'f --6 k&UII <br /> WORK PLAN DATED <br /> 9 2b 1 <br /> APPLICATION ACCEPTED BY DATE IS EA �I <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICON DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# <br /> Z2'bg $,25X7 2IZ7 — - 3/ SR# DODO*00/,933 <br /> (3500 <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOPELLERMIT APP <br /> EHD 29-01 5/09/12 <br />