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' COPY <br /> oAa�ly c SAN JOAQUIN COUNTY FILE <br /> ■■,�,,,,■■ `_ X ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> y' <br /> .• 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATIONUNIT IV <br /> Telephone: (209)468-3464 Fax:(209) 468-3433 Web:www.sipov.orq/ehd <br /> ��FOR <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 pen-nit 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 th Standards of the San Joaquin County Environmental Health Department. <br /> S 4o J C)", 'Q-� VL <br /> Site Location 3'j"0'0 5 Ca •�-� Cross Street W�s� �` �� City S U c-4-�aY.Zip APN 3\ — !t a�—� <br /> Property <br /> Owner vee..9,1- o,. s C Address P o '&--c %Z4 N City 'S�� �`-��Zip 5r2.0 Co Phone <br /> C-57 Contractor h \ cl'_ Address City Lic Phone <br /> Consultant/Sub Cntr G E L,9— Address S l YZM R'-S5 a, City 'r-- `$ -3 r. Lic Phone S -Oozy <br /> Billable Party G -F- L Q Address $ V— �L City ` Q Zip S 3 tot. Phone a %0�- <br /> GIS Coordinates:X-14 - 21(. Y —!L\ .413S <br /> \ <br /> e.l �4�� <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> (K NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER) <br /> 5FSOIL BORING IDs 2,.3 A, <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLEo� ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL r 1 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> 3 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) (� <br /> _❑INJECTION(i.e.AirSoarae.Ozone)t�HANDAUGER GROUT SPECIFICATIONS h� C>- r-\�� "'�� \ <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH S V� ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: 4�'k� c1'_\,,_ \"�\", ',r, <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 ❑OVER-BORE DIAMETER of INCHES TO DEPTH OF FT <br /> WELL IDs: ❑ PRESSURE GROUT TO DEPTH of FT BELOW SURFACE <br /> 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 prepay this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, d 1 applicabl ifornia Laws. 1 1 <br /> Signed ✓ �^ -D Title/Company <br /> Print Name A .� v v te '2> <br /> 2 DEPARTMENT USE ONLY "^l <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS J JlUD W I4t$KF1 S1zCc­Ef k i4D, l G ..� <br /> WORK PLAN DATED (D 2v Z <br /> APPLICATION ACCEPTED BY J, DAT FAAPAREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE _13- <br /> DESTRUCTION <br /> '3-DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST I PR# <br /> 9 0 S $125x 12.5 M4/2 &Z SR# Y S <br /> X103 ?5 37S Roo) <br /> PR# <br /> (2900) <br /> C-57 _ WC _ y—WAIVER 1114= C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC_ _ <br />