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' Is.. <br /> SAN JOAQUIN COUNTY <br /> LOP <br /> -rAL HEALTH DEPARTMENT <br /> ENVIRONMEN SITE ITIG T <br /> 600 East Main Street,Stockton, CA 95202-3029 UNIT I <br /> , c ,' Fax: 1 -3433 Web: ff v,a c <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AW REMEDIATION <br /> NC„I�F FtNI E.R PI FICI tCP9R Y AIS I RC} IAT B ISSLI ) <br /> Application is hereby made to San Coagtjin County for a permit to construct and/or install the work described, This application is made In compliance with San <br /> Joaquin County Deveiiipment Title,Chapter 9-11153,and the Standards of the Safi Joaquin County Environmental Health Department <br /> Nwc OF Crpowtq ST <br /> SRO Location ''.Atlt Cros StreetL 1tMB41 <br /> City TgC 1 lop � APN i " ' OL <br /> rt r A tCi 15 82 6 ' ' dress I I City <br /> jj <br /> —zp rPhonyC y <br /> o <br /> T-Sy contractor Address --- <br /> Phonea tt� — r <br /> :onsull ntlSubCntr <br /> A KA CrE t: " , Address f-0- 30X t _„_....,_ City S H 0_,N V Lic ttS 05 6 Phony l”-72 P <br /> Billable Party AA t A dress F,0- DoX t --- City p 0 L Zile 'I _Phone <br /> GIS Coordinates,x 31, T.1(a y - 1 I. L at LA T It. <br /> t I S LLISORt (CPT,GEOPROBE,I-I'YDROPUNCt I,HAND-AUGER,OTHER) <br /> C3 SAIL BORING los <br /> ELL 10s <br /> rF LL1 ( tC It ST ,LLATIO PECC T P CIFICAT'I SIS <br /> —0 MONITORING '< t HOLLOW LOW STEM INA,Or BOREHOLE F 0 MULTIPLE CASINGS 0 MULTf•LF%.'EL WELL CASING DIA <br /> 0 FXTPACTIOWVapor/later 0 HAMMEWDRWEN CASINGTHICKNESS N A TYPE OF CASING: @ EL I PVC" t OTHER <br /> I S(Ol.VAPOR PROBE Q MUD ROTARY DEPTH OF GROUT`SEAL �>_.��TREMIF TYPE'TO PF USED, 0 AUGERS 0 HOSE APE <br /> ,.__.I $O$L SORMG MIPUSH POINT(GP/CPC) GPOUT SEAL PUMPED:0 Yes No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> (��,�`kNe.asJFC'NON .4_.52 csrs) j 0€IAN0 AUGE ROU I` PE IFI A7PONS a <br /> L oTMFR: t .. ...<:._ 0 OTHER` APPROX,BORING DEPTH S� I BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CFASIN I D 0 Yes!Casing Dia: Casing Depth: floring[btu: <br /> COMMENTS: i L VA POR t SAMPLE -LOC S Ca C ) <br /> NOTE: OFFSITE WELLS& BORINGSREQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> ?� It LICT RIQN ASTR CTt I tCIJz IaFr ALL TttAT ArP <br /> r' LL($)TO 8 DESTROYED 0 OVER-BORE DIAMETER OF t CHES ccs DEP rla OF­..,.. fT <br /> L ICs. PRESSURE GROUT To DFPTH OF FTBELOW SURFACE <br /> GROUT SPECIFICATIONS AIS EXPLOSIVES FROM -TO FTBELOW su r°ACL <br /> TRE tIE TYPE TO BE USED:0 AUGERS 0 HOSE Q PIPE MUSHROOM CAP AT(13 FT) rT HELO SURFAC <br /> COMMENTS �_w <br /> WORKINGDAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPEC"T"ION I T ENT <br /> I hereby certify Haat I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, torrti�eto + s F A L S C tTSis3n c ` K . �.T+ 'C eS ajp. jyr A K t A P t M L I " <br /> Print Name Ee T t A <br /> DEPARTMENT" USE ONLY <br /> SITE MAP IN UNIT"IV FILE-SITE ADDRESS C,?� <br /> WORK PLAN DATED �� <br /> APPLICATION ACCEPTED BY <br /> µ DATE 6SSU C' l AREA._, <br /> GROUT"INSPECTION N B RNAL INSPECTION By DATE <br /> DESTRUCTION INSPECTION BY � DATE ..— _..�n.--- <br /> ACCOUNTING ONLY` AID FAC .._ <br /> SERVICE Rt <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECU"CI BY DATE I C ICE <br /> REQUESTPR <br /> a I ( T„P > L b ? wale <br /> 1x ! �! <br /> RR <br /> v <br /> C-IaT_ � y'JC ��.. AA;�t�R .. .. C•S LFTTEFt C"TF AtIT1iC7r,'I:�AI'ICbITi TG SIGN PECTfT t . .�,__,FIt�FtC7AC:IItF�I t LaC:II;, ."�m.;fi,..,�. <br /> FH17 S• I It l tI1;T ULFCrt.PERMIT APP <br />