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SAN JOAQUIN COUNTY <br /> <br />Fill COPY <br />LOP <br />1868 HazeIton Avenue, Stockton, CA 95205-6232 SITE MITIGATION UNIT IV Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.orq/ehd <br />WELL & BORING PERMIT APPLICATION <br />FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION . '' fl-A.'' w <br />I) g - <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />A : 2 : <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 w h San <br />Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. <br />CA- "-Iv v'etU si,Q\ <br />2o ? <br />Site Location113 14)6,5 ( L-N • Cross Street 0-111,1/4 KrzrocAmi on . City/State sro c krow, Zip /5-- (0 PERV-1,4 . r'' Al _ - ' <br />P- <br />Property <br />Owner ,c.4InTrz. 106-127e,vriE Address ..t. 104-1,56.0. FLALZ A City/State04k.U4r40 Zip 5 '(C/ <br /> <br />CONSTRUCTION WORK TO BE PERFORMED: <br />14, NEW WELLVORINQ(CFT, g,QPROBE, HYDROPuNCH, AND-AuGER THER) <br />SOIL BORING IDs <br />DI WELL IDs <br />OTHER IDs <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />C-57 Contractor A/ 4 Address -- C;Lty/State — Lic — Phone --- <br />Consultant/Sub Cntr 1C:2402.€ Addressicno 6 y to 40 ItiCK 0 le ,14-eity/State r8 1 g74/5"/ Phone <br />Billable Party PA-012-6- Address ChtiF ili-3 Al'atia City/State Zip Phone <br />GIS Coordinates: x (0,T3 t 5 /3 (.1 Y 2 11 r5b5.4" <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 3 si 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS WA- TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />DEPTH OF GROUT SEAL—C4% 3 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED: 0 Yes tklo (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />GROUT SPECIFICATIONS A./EA-r etur- <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br />CONDUCTOR CASINGV,No 0 Yes: Casing Dia: Casing Depth: Boring Dia: <br />TYPE & # OF WELL/BORING INSTALLATION TYPE <br />MONITORING HOLLOW STEM <br />0 EXTRACTION: Vapor/ Water 0 HAMMER/DRIVEN <br />0 SOIL VAPOR PROBE 0 MUD ROTARY <br />SOIL BORING 0 PUSH POINT (GP/ CPT) <br />0 INJECTION (i.e Air Snarne. Ozonertg..HAND AUGER <br />0 OTHER: 0 OTHER: <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 El OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br />WELL IDs: El PRESSURE GROUT To DEPTH OF FT BELOW SURFACE <br />_GROUT_SPECIFICATIONS 0 EXPLOSIVES FROM TO FT BELOW SURFACE_ <br />El MUSHROOM CAP AT (3 FT) FT BELOW SURFACE <br />COMMENTS <br />TREMIE TYPE TO BE USED: El AUGERS El HOSE El PIPE <br />5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />pared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and I hereby certify that I have <br />Regulations, and ppli e California laws. <br />Signed <br />Print Name ALA- AI ft-urz k 0-1 c- <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS 3 2'3 hJE-sr- 409,tx. <br />cr0Loce Jr/2. pA-0(7£ Afj Gt. tv c <br />1411V 1.7 Date <br />Title/Company <br />DA SSUE <br />GROUT INSPECTION BY FINAL INSPECTION BY <br />- <br />DESTRUCTION INSPECTION BY DATE <br />COMMENTS/CONDITIONS: <br />ACCOUNTING ONLY: AID # <br />N <br />FAC # <br />PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE <br />REQUEST <br />RO # <br />PR # INVOICE <br />2..C1 0 5 $ 125 x 1 <br />5 c-Z-) <br />9 3 /6 7 <br />(i ir,C.t V•kk 41-25--/ sR# 4 705-7 <br />2S c-) 3 3 -75- <br />I* '13 066 RO # <br />(3500) <br />PR # <br />(2900) <br />WORK PLAN DATED <br />APPLICATION ACCEPTED BY <br />PetZ, 2,.ot <br />. -2 4.- 3 AREA <br />DATE <br />C-57 WC <br />EHD 29-01 5/09/12 <br />IV WAIVER Iv C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT k-- ENCROACHMENT DOC R.I4 <br /> <br />WELL PERMIT APP