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°tout SAN JOAQUIN COUNTY l <br /> E ONMENTAL HEALTH DEPARTANT r <br /> w: I ` LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> " •;Fo::•;;.P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.s' ov.or iemT <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIAT <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 201¢ <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health DepartRVICES 'I <br /> Site Location S S- �6ZICA VCro s Street I— l.(�0(L77l E MIT/SERVICES <br /> Property' /+�" City/State 571ZUW✓ Zip 95x06 APN Ill f• oZJA- <br /> owner i1�'lal�a_l g„yt fl�fiaJ �11.rtrAA dress .2//y 4Z� /�1G 4(f City/State�irEG=rW Zip gS2o6"Phone Z01 •KW.3U5� - <br /> C-57 Contractor fitk Address 3000 Da�,/Innu g 5treGf city/state`.k+c;.ru.�LIC Q/10 Phone 9/G-G38-1(�g <br /> ConsultantlSub Cii ntr I"F /ZNL`- Address 2Z3S�•I�QO(,yQ,yy✓.F./ City/State5rt� Lic P(7Z"iy(-:4 Phone <br /> '70-4 5-23-/c/ <br /> Billable Party Sy/hx Address ct/5'0 City/State Zip Phone <br /> GIS Coordinates: yQr•1 V (ac. /9 1 1-v r_ .. z a. l.4r: '57,q`15°950® w.N6 ,. lZl.ZSr73N 30 <br /> -121 SO <br /> CONSTRUCTION WORK TO BE PERFORMED <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> �❑r SOIL BORING IDs <br /> r_ry _ <br /> WELL IDS Mw� <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 14'MONITORING <br /> HOLLOW STEM DIA.OF BOREHOLE SS it ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: n <br /> _0 EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS SCI'l Ldn TYPE OF CASING: ❑STEEL BrPVC ❑ OTHER <br /> _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 71 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE PIPE <br /> _O SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:t8 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> pp (/O rIY6v7dR//74' <br /> _I7INJECTION[.e.AirBoaraeOzo 1❑HAND AUGER GROUT SPECIFICATIONS 5- Pt-i.(r POaTf t� f56NT Q•( We76r/T <br /> _❑OTHER: ❑OTHER: _ APPROX.BORING DEPTH SD BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING Io❑Yes:Casing Dia: Casing Depth:_ Boring Dia: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <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: <br /> GROUT SPECIFICATIONS E3OF PRESSURE GROUT TO DEPTH FT BELOW SURFACE <br /> El EXPLOSIVES FROM TO FT BELOW SURFACE <br /> COMMENTS <br /> TREMIE TYPE TO BE USED.❑AUGERS ❑ HOSE LJ 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 th ha a preparetl,tgyg application nd that the work will be done in accordance with San Joaquin Cou n Ordinances, Rules and <br /> Regulations,and �plicable alifornia law . 0,, / / 1 <br /> Signed r'r'�- Title/Company J[WJr.-r( f�iL0 C15-, �(9 �7 <br /> Print Name w Date 71/Gl�O/q <br /> ©©4�"� DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS VXc.> S $ r--C- 5' rKpnyj <br /> WORK PLAN DATED to t4 <br /> APPLICATION ACCEPTED BY J Nni9.Cr.r.u/\ DATEISSUED _7Z/-(y AREA /6Y <br /> GROUT INSPECTION BY FINAL INSPECTION BY — <br /> DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COM MENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# <br /> REQUEST PR# INVOICE <br /> 3 $125x 37I P36ce douN 7-� I SR# 7v7o()Mo <br /> 3500) <br /> PR# <br /> (zsoa <br /> EHD // WC WAIVER�� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC o f <br /> EHD 29-01 B/09/72 <br /> WELL PERMITAPP <br />