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i <br /> SAN JOAQUIN COUNTY t � <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> a <br /> SITE MITIGATION <br /> :. 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> Telephone: (209) 468-3147 Fax: (209j 468-3433 Web:vvwws oV.or lehsi <br /> ��FOR D <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 OCT 0 9 2013 <br /> Application is hereby made to San Joaquin County for a permit to construct andlof install the work described. This application is TOWN0211ffffl&M <br /> Joaquin Count evelopment Title,Chapter 9-1915.3, and the Standards of the San Joaquin County Environmental Health DepartmThMI SEI VICES <br /> �Z . •� ,'yctt Cross Street 'ern City/ a'f'te"� / �� zip ��Z04 APN o <br /> Site Location !Y p�'f � t[ <br /> OwnerProper61T VI 1070a47DAI AddreJV5At-,r/�0>•&4',V � Ci ! tate / C Zip 952rap _Phon yT <br /> Owner `���� <br /> C-57 Contra t�rN r��G99Ot/C ri/l Address W• Cit Stat / C Lic Phan 661 -76,00 <br /> ConsultantlSu��hZ--Y'�'v�Vl%p 6v4 jdyy,ress f �' �rI to `r �� Lic S�t1 Phan 9t' 9 9` <br /> Billable Party t{f�►�KlQr rdd, O 0-' )M4ess r'P tSfH. aD br.�in`��r7 City/S a4e"-" Co ziA �Oa/ Phone 30 0--401 <br /> GIS Coordinates:X�•930311 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 IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _Q MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> —❑EXTRACTION:Vapor/Water ElHAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL [jPVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING 0 PUSH POINT(GP!CPT} GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION('a Ir SpaMe.Qzone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: Cl OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dla: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED- I DESTRUCTION METHOD: C H ECK ALL THAT APPLY) <br /> #OF W�Ly(5 9 ES ROYED OIhHII f pitirr`+re g � OVER-BORE DIAMETER OF ----_INCHES TO DEPTH OFSO"S8 FT <br /> WELL IDS: w �� f;t PRESSURE GROUT To DEPTH OF (p O FT BELOW SURFACE <br /> GROUT SPECIFICA IONS cc me Lt EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE PIPE MUSHROOM CAP AT(?3 FT) 3.0 FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I ve prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and 7�1 <br /> mSignede/ <br /> Print Name Dae 0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE <br /> /�-SITE ADrD/KESS L•p` <br /> Ge <br /> WORK PLAN DATED OC- ° l �t <br /> APPLICATION ACCEPTED BY DATE ISSUED /0///1201 T AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> I <br /> COMMENTSICONDITIONS: l <br /> ACCOUNTING ONLY: AID# ' FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> i REQUEST PR# <br /> � $,25x_. <br /> R ff <br /> 00) <br /> PR# <br /> (2900) <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORI7-ATION TO SIGN PERMIT _ ENCROACHMENT DOC <br />