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SAN JOAQUIN COUNTY 1%./ <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street,Stockton,CA 95242-3029 SITE MrMATtQN <br /> •l <br /> Telephone:(209)468-3464 Fax:(209)468-5433 Web:www.sinov. rglehd UNIT IV <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES'I YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct andlor 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 Departmaht. <br /> Site Location 184 Du-+a Aiy Cross street _I.IJL e-Ioo Rd city 5'rbck�yn zip-.I Sa05 APM �✓ <br /> ownev I h W4W Address EnGvol2 rk"xi+ Army' City Pand( Zip Phone <br /> C-57 ContraeWr $ress 'PD.fox ASS9 City n�Lic bqa Phone 916.9 .0333 <br /> ConsukantfSab Cntt jr6A H-Ian cM Address P.O. 'I'lM aSS of City Qffr�v�Lie'13co,I1 Phone_916R90.0333 <br /> 13elabl9 Party j,>e :S 6 a Address & tic 7 330 City V&rl-uro_ Zip33001- Phone SbS.64,a,If <br /> Gl$Coordinates:X Y <br /> S <br /> NEW WIELLIROMNG(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> [3 SOIL BORING IDs <br /> 0 WELLiDe <br /> 0 OTHER IDs <br /> TYPE&tt OF WELL00RING I[ND-TALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> —0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _Q 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 0 PIPE <br /> _O,SOL BORING O PUSH POINT(GP/CPT) GROUTSEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION'Me.AfrSeaw&oimel❑HAND AUGER GROUT SPECIFICATIONS <br /> _D OTHER: Q OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING p No❑Yes:Casing Dia: Casing Depth: Boring Da: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&SORINIGS REQUIRE.ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> P F. O£S IRUCTtON METHOD:(CHECK ALL THAT APPLY( <br /> 0 _#OF Wa.L(S)To BE DESTROYED 0 OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IN: CORESSURE GROUT To DEPTH OF 3 FT seLOw sURFACE <br /> GROUT SPECIFICATIONS h eAa+ El EXPLOSIVES FROM Tfl FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:0 AUGERS LWHOSE 0'PIPE ❑MUSHROOM CAP'AT L3 FT) FT BELow SURFACE <br /> COMMENTS- <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby car*that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Rogetlattons,and all ap cable alit nia Laws. <br /> Signed n- <br /> g�� Tltie/Company l t &C.Cacm f Lo"os ErW i rbnny_^+n I Inr, <br /> Print Name �- &nse % Date 3�i��(i <br /> �^ DEPA Qff U E ON Y <br /> SITE MAP IN UNIT IV FILE SrfE ESSo 'J bt7 to <br /> WORK PLAN DATED 11IL1112— <br /> APPLICATION ACCEPTED BY DATE ISSUED <br /> AREA <br /> GROUT INSPECTION BY FINAL <br /> TIO <br /> BY <br /> DESTRUCTION NS ECTION BY DATE 1 7�CU7l�' RATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# REGV'D BY DATE SERVICE RO# INVOICE <br /> 352(_,, .� �—n REQUEST ,PSR* <br /> 22 $125x-2- Lac/ 3 � L� t SRs�' 6�I� t o <br /> 7S__ tf Ro III <br /> 3 7 <br /> 3500 <br /> Fit# <br /> 2900 <br /> C-57 WC WAIVER 057 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />