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SAN .IOAQUIN COUNTY � ���� r <br /> y_ <br /> EN ONMENTAL HEALTH DEPART NT <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 LOP <br /> Telephone: I SITE MITIGATION..... <br /> phone: (209) 468-3147 Fax: (209) 468-3433 Web:www.s' o�v.or I T <br /> WELL & BORING PERMIT APPLICATION n <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIAT <br /> JW NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED fl ZOi4 <br /> Applicationreby made to San Joaquin <br /> Title Chapter f3,anor a d h ilto construct Standards of the/or San Jtoalthe workquin County Environmental application <br /> Fdehl�l�l <br /> Site Location aA S-Atonic o, 7T /� PERMIT/SERVICES <br /> Property Cross Street ✓- w0'2 Cit /State 571TU7a�/ <br /> Owner Ir^N/¢/y 0..� �kn�fiurJ za0taAddress .�//�} ,r' -L G City <br /> Zip ��Ja06 APN lH� <br /> C-57 Contractor ��e- City/State"lfA t.ICY'DN zip 95206—Pnone 20 •`i�•34.>S <br /> / rill` Address 3800•Dalu�d. SfMi¢ City/State`.Sac;.rstrLQgO phone9(b'/o' $'1/(0 <br /> ConsultanVSub Cntryl-1 Dt ZA+C• Address -173;5-,,.1V ne+°y'Q,Q/ �/ <br /> Billable PartAddress ¢,'F( City/State Stn/F}, Lic Pf7Glt phone �O�•�jZ$•/J(O <br /> Y— &*A <br /> GIS Coordinates:X /'� City/State Zip Phone <br /> r,.a-r: s7.atis�s®® t.��e . Izl.zs�3w3° -- <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> DWELL IDs . 1W_ <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 1�MONITORING HOLLOW STEM DIA,OF BOREHOLESS�r r <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING OIA: Z <br /> CASING THICKNESS SGI'L Wf) TYPE OF CASING: [I STEEL ErPVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Z I <br /> ._❑SOIL BORING TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE PIPE <br /> ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:21 yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION ReAr Spame,Ozone)11 HAND AUGERp <br /> GROUT SPECIFICATIONS 1"�i y f37AY-.-tM uwT 6y ww6tH' <br /> _❑OTHER: ❑OTHER: _ APPROX.BORING DEPTH_ <br /> BOLTED TRAFFIC BOX OR 13 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING No 0 Yes:Casing Dia: Er <br /> Casing Depth:_ Boring Dia: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: <br /> #OF WELLS)TO BE DESTROYED DESTRUCTION METHOD•!CHECK ALL THAT APPLVI <br /> WELL IDs: ❑OVER-BORE DIAMETER DF INCHES TO DEPTH OF <br /> GROUTS ❑PRESSURE GROUT TO DEPTH OF <br /> TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE LJ PIPE ❑EXPLOSIVES FROM FT BELOW SURFACE <br /> COMMENTS ❑MUSHROOM CAP qT(>3 Pf TO FT BELOW SURFACE <br /> FT BELOW SURFACE <br /> 5 WORKING DAYS NO�T�ICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify th�t'�a e prepare"d,tW application nd that the work will be done in accordance with San Joaquin Count Ordinances, Rules and <br /> Regulations,and PplicabIs alifornia law . <br /> Signed - o <br /> Print Name J <br /> Title/Company bCJrAf xo 61S' o <br /> pp DEPARTMENT USE ONLY Date 77lG��/J/c/ <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 8910 S 4 r"( 2 IAia $ <�E O <br /> WORK PLAN DATED /" (y J �[f�'C <br /> APPLICATION ACCEPTED BY _ J. <br /> GROUT INSPECTION BY DATE ISSUED2/-!�•/ AREA /G Y <br /> DESTRUCTION INSPECTION BY FINAL INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: DATE <br /> ACCOUNTING ONLY: AID# <br /> PE CODESFEE INFO AMT REMITTED CHECK# FAC# <br /> RECV'D BY DATE SERVICE RO# <br /> CIO / REQUEST PR# INVOICE <br /> ? $ 125 x I ��3V OZ eUL[N 7'/�; ! SR# ton <br /> Cat <br /> Mo > 37 KU <br /> (3500) <br /> PR# <br /> C-57_-- WC 2900 <br /> EHD 29-01 5/09/12 WAIVER---I4 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC <br /> WELL PERMIT APP <br /> t. <br />