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SAN JOAQUIN COUNTY FILE <br /> z ? ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> '�'�:• 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> Telephone: (209} 468-3454 Fax: (209) 468-3433 Web:wrrvws' ov.or lend <br /> Vp / <br /> 3 <br /> WELL & BORING PERMIT APPLICATION D /V <br /> D FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> ✓✓✓ 1 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 5`05 <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 1Z5b N.lViLskoy Wky Cross Street -if- 0*�atAI� �1f�1. City 0XV-1001J Zip 9SZDS APN 1173/001 <br /> Property II <br /> Owner 8ES-1 C444 of- CA4. L1'd. Address &L4 Ith/6t 4t.-„01Vtf CityZip goflo Phone(9;0 Z - <br /> C-57Contractor ISCr AIY.•6"e ' Address 1/350 MDAHEt- P+GLPi. City Altft C*4*W LicjKS« Phone(%6 $53^$f7/D <br /> Consultant/Sub CntrCS6N+1AV94c. Address A.II Z23Y Cityfs�04 Lic_55 IF Phone(VY)SS -S <br /> Billable Party FW CAUf4-Edit OA4L2 Address 43I<<jMf9&t_." City i&fLS*40 Zip 067* Phone S62 921 `3sti <br /> GIS Coordinates:X. 7T�_j%_ -Y=_ --t24,'�'�-rj <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HANG-AUGER.OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> X OTHER IDs - U 1� <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLt t f�❑MULTIPLE CASINGS❑MULTI-LEVEL WEI.L CASING DIA: �] <br /> I —0 EXTRACTION Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER \�A_ <br /> SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE IZ!5 <br /> _❑SOIL BORING JK PUSH POINT(GP/CPT) GROUT SEAL PUMPER❑Yes ❑Nv(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i,e.Air Soarae.Ozone}E]HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 'S Q BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> { COMMENTS: 1f <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 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 /> 1 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,a all applicable California laws. (� <br /> Signed TitlelCompany �ko�at� $E37 E'40 A4l *- 6Llo <br /> Print Nam Dae <br /> DEPARTMENT USE ONLT <br /> S MAP <br /> IN UNIT IV FILE-SITE ADDRESS �� �^�'� 1114, <br /> t ORK PLAN DATED 'Z—/ / <br /> APPLICATION ACCEPTED BY DATE ISSUED l AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> } DESTRUCTION INSPECTION BY , DATE <br /> lfi COMMENTSICONDITIONS: d+ <br /> 'r <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY j DATE SERVICE RO# INVOICE <br /> REQUEST q PR# <br /> 350 <br /> $ 122. I ZZ. SR# L3 <br /> RO# 5s� <br /> bJM 7 �/ 3500 7 <br /> O <br /> C 57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC 444- <br /> i EHD 29-01 07!28130 FILE <br /> Q <br /> O WELL PER TAPP i <br />