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cka`uv! c <br />A��FORN� <br />• SAN JOAQUIN COUNTY I* <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />FILE <br />LOP <br />600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br />Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sigov.org/ehd UNIT IV <br />p <br />WELL & BORING PERMIT APPLICATION o <br />FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION FEB 2O1Z <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 inI� IIIOiI�(1�aNEAL11 <br />Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. OPER <br />Site Location&l0 S. A1rfbI2T INCross Street "7rl450 N city <-124,M 1,1 Zip S -U6 A P N 177- 7 06-a U�- <br />Property <br />Owner to AP44 Address IQWQ M 'bCity LkAn4a ZiP !g5(a55- Phone U-30 - <br />C-57Contractor !4N?-IPbkddress -M5 Wl61y1 AM Dp City �M6J• Vl. Lic_ `;Ol Phone <br />Consultant/Sub Cntr br� Address rn 7 N L i�f $jam F+iIAL- y2lty jP�MN�f G(ZIL Lic Phone Geo <br />Billable Party C��{ y Address I( ( ',L� t City MAIIAX Zip ISL55 Phone9l(, 9�T(3Z'% <br />GIS Coordinates: X _ 57 APfl�­ Y lzzzs(_r/ <br />V UBORING (CPT, GEOPROBEHYDROPUNCH, HAND -AUGER, OTHER) <br />SOIL BORING IDs CSk4 --we-1 GSINA 5 W- . - Z. <br />❑ WELL IDs <br />❑ OTHER IDs <br />TYPE & # OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />_❑ MONITORING O HOLLOW STEM DIA. OF BOREHOLE 2:ti5 ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: W A— <br />_❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS P X TYPE OF CASING: O STEEL O PVC O OTHER <br />—0 SOIL VAPOR PROBE C3 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: El AUGERS O HOSE O PIPE <br />_52/SOIL BORING PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: 2 Yes O No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />_❑ INJECTION (i.e .Air Soarae. Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS Vii' <br />_0 OTHER: O OTHER: APPROX. BORING DEPTH 10', 40' L+ -_i ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />COND CTO CASING ❑ o ❑ Yes: Casing Dia: Casing Depth: Boring Dia: <br />/ �f L <br />COMMENTS: 1— SPDC 6.U� LP'--A-Q _ QYt.I �'0 1.w c• S�i ( C"LAJ,, n,, v 4, ,ATT. �� /,J caw .1A <br />L4Iwi ­. 1/ <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT 13ERMITS <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: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br />GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br />TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT (?3 FT) FT BELOW SURFACE <br />COMMENTS -n Rt 'nAnc� iu ,orO %161 IJF,29 r -=" Cnir A 2viVT-. TP 1t 111 f E ­7'9� trfC <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 a I pplicable California Laws. /r <br />Signed Title/Company <br />Print Name Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE SITE ADDRESS O S. !Q 41.4ZS <br />WORK PLAN DATED Z ( �IZ two <br />APPLICATION ACCEPTED BY DATE ISSUEDA- 17-IZ 17 - AREA IG <br />GROUT INSPECTION BY ., x FINAL INSF0dD"1=XW DATE <br />DESTRUCTION INSPECTION BY DATE�— <br />COMMENTS/CONDITIONS: <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE <br />SERVICE <br />REQUEST <br />RO # <br />PRPPR ## <br />INVOICE <br />'2 <br />$125, <br />4 J` <br />SR# f�l/1�`f -V <br />RO # <br />3500 <br />iso ��-1 <br />