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N r. RIGINAL <br /> SAN JOAQUIN COUNTY <br /> •�r4 .pG <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> j 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Lq <br /> -� :�� Telephone:(209) 468-3147 Fax: (209)468-3433 Web:www.alaay.orcilehd UNIT IV <br /> �oRi; <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 /> !k <br /> Site Location S�L 0Aic%e Cross Slreet City/State ri►rt Zip 4-33 U APN� 1-Zr - O`2-� <br /> Property <br /> �a lE'gu AV��Lli° of <br /> Illo 54 II /� <br /> �u j-, L.L,C, Address r� r�,� a� CiLylState Zip UO(O'T Phone 3)U—601 -3707 <br /> C-57 Contractor Address t:t0 I[Lck 0'4�&Dr. City/State J 4Vr1 Lic7ZC90q Phone r' 9- a DO <br /> Consultant/Sub Cntr (-N�' Address !;1L91•,1.r(�A.dAfa- �c- A CitylState Llc n1�A Phone ZG-0 2- <br /> Billable Party �N�c� Address _ 1' City/State Zip ��Phone <br /> GIs Coordinates:X 21 Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER I <br /> TYPE;8#OF WELLlBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _[ EXTRACTION:Vaporl Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC E] OTHER <br /> _[I SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL_DEPTH IS$0 FT) <br /> _❑INJECTION(i.e.Air Soarme.onne)I]HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR I]STOVE PIPE <br /> CCNDUCTOR CASING❑No❑Yes:Casing Dla: Casing Depth: Boring Oia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOI]: CHECK ALL THAT APPLY <br /> — — OF WELL(S1 TO BE QESTROYED A OVER-BORE DIAMETER OF INCHES TO DEPTH OF��FT <br /> W LL IDs: ry ❑PRESSURE GROUT TO DEPTH of FT BELOW SURFACE <br /> GROUT SPECIFICATIONS 1,10,,4 /it P'L-j- ❑EXPLOSIVES FROM TO FTBELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE [E PIPE ❑MUSHROOM CAP AT L3 FF) FT aELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Or trances,Rules and <br /> Regulations,an al applica California laws. <br /> Signed TltlelCompany r MP:1 1 JG,�'n I)P� 6 m C, G! <br /> Print Name Date-- I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 7� P rQ IL1 Hen <br /> WORK PLAN DATED <br /> jr <br /> APPLICATION ACCEPTED BY_ `(r76`J +'r'' t DATE EAl <br /> GROUT INSPECTION BY FINAL INSPECTION BY _WTE S Z2-r<I <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMTREMITTED CHECK# RECV'DBY DATE SERVICE RO# INVOICE <br /> C REQUEST Pit/# <br /> $125 x C Q-N r J-l 2-1 S R# <br /> RO# <br /> 35nn <br /> PR# <br /> (2900 <br /> C-57 WC L WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOCVV 4 <br /> EHD 29-01 5109112 WELL PERMIT APP <br />