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.. ul <br /> SAN JOAQUIN COUNJYc��` ED <br /> ENVIRONMENTAL HEALTH DEOV LOP <br /> SITE MITIGATION <br /> •• 600 East Main Street, Stockton, CA 95202- <br /> Q..; Telephone: (209) 468-3454 Fax: (209) 468-3433 Web slaov.org/ehd UNIT IV <br /> ��FOR <br /> WELL & BORING PERMIT AP WR&j"L�HEALTH <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVE TICNI�S�YtYI•iCfEDIATION <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 <br /> Standards of the San Joaquin County Environmental Health Department. 175-170_ <br /> �1'I? — 9 <br /> Site Location / Y✓V4 je Cross Street POkM� City Zip l S206 APN <br /> Property �y D !/ FDhf WO�� 4/S-®3s <br /> Owner �Oc>�L�Gu%� Address,QCRQ� ft4k(4kCity Zip /7(y102 Phone 8/n7- / G.,7 <br /> C-57 Contractor Yee 51, � Address 23�M-►+Ur City t� Lic (o✓?4O5F1 Phone�I J7�o l,2 <br /> Consultant/Sub Cntr Address a8�o6�frw`tiy0akst�r �Ciitty C.kkAy►1fkfV Lic Phone y!b 09 a3�3 <br /> Billable Party Address Sa-h'lA City Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑ SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑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 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.AirSparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑N ❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: �� /►'//T T�� f/J?CJ r,lJ� 3t*V1cc.K..G�f��S�, Al <br /> W611 = $7< <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: In W- 1l /"W 3 PRESSURE GROUT TO DEPTH OF 2S7"3Z- FT BELOW SURFACE <br /> GROUT SPECIFICATIONSryj�e / O and w 3'� i EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERS ❑HOSE ❑ PIPE $J MUSHROOM CAP AT(>3 FT) 1-4 FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certif t t I have prepar this appl ation and that the work will be done in accords a with n Joaquin County Ordinances,Rules and <br /> Regulations an I p' bleC if r i a <br /> Signed Title/Company <br /> Print Name //LL Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> 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 PR# <br /> $125 x SR# <br /> RO# <br /> (3500) <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />