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C-57 Contractor <br />Consultant/Sub Cntr <br />FILE Cnpv <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sjqov.orq/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 />LOP <br />SITE MITIGATION <br />UNIT IV <br />Site Location <br />Property <br />Owner Address <br />/5 Address <br />Address <br />Cross Street 511N 1,.)e6x4-140 \\-) 0 zip q5do APN 11 q1 -3)r7 <br />eeTio.0.4 city itcn zip \--,77 Phone a02' - c) 7Zet,-,0 <br /> <br />'Fa ( 33(.0 ' city"K.4i) 1)1i7t Lic 7/007 ei Phone 70 7- 3 N--`13')(2. <br /> <br />Po---5.)„( 1164 Cita--54,u. refit Lic ng Phone 3 r7 <br />Billable Party ETIL) v -0 ss Address Po Boy 115 41 citientinw, Cery <br />GIS Coordinates: X 37. 9 7 tp079 Y - tr? J. OS I <br />Zip Phone 3 77 - <br />CONSTRUCTION WORK TO BE PERFORMED: <br />Ai NEW ELL/BORING (CPT, GEOPRQBE, HYDROPUNpH, HAND-AUGER, OTHER) <br />SOIL BORING IDs (3) - (k r • <br />WELL IDs <br />0 OTHER IDs <br />TYPE & # OF WELL/BORING <br />0 MONITORING <br />EXTRACTION: Vapor/ Water <br />SOIL VAPOR PROBE <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />ID HOLLOW STEM DIA. OF BOREHOLE 3' MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />o HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />13 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS El HOSE 0 PIPE <br />J2rSOIL BORING 0 PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: 0 Yes 0 No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />0 INJECTION (i.e Air Soaroe. OzonelvdHAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: 0 OTHER: APPROX BORING DEPTH Ff -t. 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br />CONDUCTOR CASING 0 No 0 Yes: Casing Dia: Casing Depth: Boring Dia: <br />COMMENTS: <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 0 OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br />WELL IDs: 0 PRESSURE GROUT To DEPTH OF FT BELOW SURFACE <br />GROUT SPECIFICATIONS 0 EXPLOSIVES FROM TO FT BELOW SURFACE <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> <br />0 MUSHROOM CAP AT (1.3 FT) FT BELOW SURFACE <br />COMMENTS <br />5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />I hereby certify tha I havqrepared this application and that the work will be done in accordance with San oaquin County Ordinances, Rules and <br />Regulations, antall app7able California Laws. <br />/z-• <br />ff.? 5.1'A— I L e 7. / ,/ /A ./ Signed Title/Company <br />Print Name --qirPC-5 1'417 r") 'Date f <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE SITE ADDRESS 3 (4) T-6e-f-/-X.) Py.,At-) <br />/O7 2I?.. <br />t-/ K"- <br />GROUT INSPECTION BY FINAL INSPECTION BY j/ E Tr- <br />DATE <br />WORK PLAN DATED <br />APPLICATION ACCEPTED BY <br />DESTRUCTION INSPECTION BY <br />COMMENTS/CONDITIONS: <br />AREA <br />DATE <br /> <br />DATE 7 <br />DATE ISSUED <br />ACCOUNTING ONLY: AID # FAC # <br />PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE <br />REQUEST <br />RO # <br />PR # INVOICE <br />$ 125 x 1 /2c. <br />-5 1 z 1 7-te___ 6 -5-22(2 SR# 6 505 3 <br />01 9 -7- 3 24157,-) RO # <br />(3500) <br />PR # <br />(2900) <br />C-57 A.11,1 WC WAIVER /1.4j- C57 LETTER OF AUTHORIZATION TO SIGN PERMIT A/ VI- ENCROACHMENT DOG