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ORIGINAL <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> P Telephone:(209) 468-3147 Fax:(209)468-3433 Web:www.siclov.orglehd UNIT IV <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES I 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 /> Site Location 40 l S�� Cross Streat L.:«.) P...(c Cityl5tate ZIP. fi5135 APN._�l- Zl- 8zc� <br /> Propertyl/�vrr�� <br /> Owner_U�,sl u,F{.ru, Address 310 Tnu nc Cr r,1r, %r. City/State !!4�v -/C4Zip 1S6653g Phone Zo5-174 t-3&0 <br /> 'n <br /> C-57 Contras of r Ulf Jru e'll", Address 360& h-LL C,r,.& Ns City/State,9Rjjb,,jL�ic_T Phone 2a -1900 <br /> Consultant/SubCntr eNGE7 ,.u,�� Address W r11.W.'N.c, Avaj d1-A Cilytstale Vip"&ALlc ✓1 44 Phone ZD,i- L6K•14a <br /> BiltableParty E'NGIiv 'r, Address City/Stale 4 Zip ,, Phone <br /> GIS Coordinates:X 37 Y. `IZ r 30&, U}- 6" <br /> "��fztoot4 06 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL(BORING(CPT,GEOPROSE,HYOROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> l ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING El HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor!Water ❑HAMMERIDRIVEN 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 Argeame.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER; ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS; CONDUCTOR CASING❑No ElYes:Casing Dla: Casing Depth; Boring Dia: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:cCHECK ALL IUAT APPLY) <br /> t #OF WELL(S)TO BE DESTROYED ®OVER-BORE DIAMETER OF L'! INCHES TO DEPTH OF_12-_FT <br /> WELL IDs:_IA V El PRESSURE O <br /> PRESSURE GROUT TO DEPTHF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS A= e-n ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED;❑AUGERS ❑HOSE I9 PIPE ❑MUSHROOM CAP AT L3 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 prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and at cable California laws. �- <br /> Signed TillelCompany�Wra_ yo , "-, ON C& _m., <br /> Print NameLil .. Date 1-14.01 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 70 77m T4A-) Tlf P-a P <br /> WORK PLAN DATED M v I C( <br /> APPLICATION ACCEPTED BY U r l vd DAT AREA_623 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE -2 f.1 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAG# <br /> PE COTES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> Q REQUEST PR# <br /> S 125x cx.> ZU�IU CI-(- SR# <br /> RU RO a <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER�_ C.57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOC NLL <br /> EHD 29-01 5109/12 WELL PEA IT APP <br />