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�x�f.co <br /> SAN JOA <br /> QUIN COUNTY <br /> �ICd: ENAONMENTAL HEALTH DEPARTIV <br /> C&P�!' <br /> - <br /> � a 1868 Hazelton NT <br /> <"FoaN` Te%phone: Avenue Stockton, CA 95205-6232 SITE <br /> (209) 468-3147 Fax:(209 468- <br /> WELL � E30RING <br /> 3433 Web:wwW,s• D�.or /ehd M. IGATtb`N <br /> IT lit <br /> FOR WELLS AND BORINGS USEDFORCONTAMINANT INVESTIGATIONS UN <br /> APPLICgTlO�� <br /> Application is hereby NON-R�FUNDgBLE PERMIT EXPIRES 1 YEAR FRO <br /> Joaquin Coun y made to San Joaquin Co AND REMEDIATION <br /> ty Development Title, Chapter g_7 county a permit to constructM DATE ISSUED <br /> Site Lo and the S and/ install the work described. This application <br /> Pite Location�a �,AZ{aelcl"v- tandards of the San Joaquin County Environmental Health pe is made in co <br /> Owner YAC Cross Street _ . LI.G,.o�-r/ compliance with San <br /> ��ii °4u �,uD TfG1�PRoAaa-n�s _""''r�i' City/State '5(V0jV,1 Partment. <br /> C•57 Contractor Address �(Jp( C GGM5' ��Zip C/,S <br /> ConsultanUSub Cntr Address �u 7duG 57- (.C.tsNrVR'+ APN fy •a9a�13 <br /> p SP�f City/State p Np <br /> NC- City/State G/.Sac/r[M zip! <br /> Billable Party Address;2235/h�0u `�ic 93d'i <br /> GIS Coordinates.X �� w ��CitY/State Phone <br /> 7/ <br /> Address .. 6 I <br /> Y tiT Lic( jYj'.��1 Phone <br /> CONSTRUCTION WORK 70 11w-6 CEr_ City/State 52�fo D <br /> �.� -Izl. S 3`794s�ob Zip Z�Phone <br /> ❑NEW WELUBORING cpr, BE PERFORMED: w ar: <br /> ( GEOPROBE,HYDROPUNCH,HANG- y45 �3 LOUJ`f4 y�e — <br /> E L BORING IDs 2 8o Sb b° <br /> WELL IDs ll/_ AUGER,OTHER) <br /> D OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE <br /> �R MONITORING �� CONSTRUCTION SPECIFICATIONS <br /> _O EXTRACTION:Vapor/Water 'HOLLOW STEM DIA.OF BOREHOLE g" <br /> —�SOIL VAPOR PROBE 0 HAMMER/DRNEN D MULTIPLE CASINGS <br /> ❑MUD ROTARY CASING THICKNESS �j(�,- t•(D ❑MULTI-LEVEL WELL CASING DIA: Z.Ir <br /> _0 SOIL BORING DEPTH OF GROUT SEAL�TYPE OF CASING: 0 STEEL <br /> _D INJECTION li a A S ae O D PUSH POINT(GP/CPT) GROUT S ,��� TREMIE TYPE TO BE USED; �O D OTHER_ <br /> ��!DHAND AUGER EAL PUMPED:�Yes ❑AUGERS <br /> _0 OTHER GROUT SPECIFICATIONS t N0(MAXIM1r FREE FALL DEPTH S 30 O HOSE�PE <br /> ❑OTHER- r�JIL'2,1-,L� - /� � I�fO 8f)V7 ,,;W <br /> —APPROX BORING DEPTH / <br /> COMMENTS: CONDUCTOR CASING 11 BOLTED TRAFFIC BOX OR <br /> NOTE: OFFSITE WELLS 8, BORINGS N0 0 Yes:Casing Dia: D STOVEPIPE <br /> Casing Depth: <br /> DESTRUCTION WORK 70 BE PERFORMED: REQUIRE ACCESS � Boring pia: <br /> #OF WELLS)TO BE DESTRoy® AGREEMENTS OR ENCROACHMENT PERMITS <br /> WELL IDs: DESTRUCTION METHOD: <br /> GROUT SPECIFICATIONS ❑OVER-BORE DIAMETER aFECK ALL THATAPPL <br /> TREMIE TYPE TO BE USED:❑AUGERS D HOSE PRESSURE GROUT To DEPTH OF INCHES TO DEPTH OF FT <br /> COMMENTS D PIPE D EXPLOSIVES FROM —FT BELOW SURFACE <br /> D MUSHROOM CAP AT >3 FT) —FT BELOW SURFACE <br /> 5 WORKING;DAYS NOTICE RE —FT BELOW SURFACE <br /> hereby certify th 1 11 ra REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION <br /> tegulations,a U p P re'd( is application ntl that the work APPOINT <br /> PPlicable alifornia;els <br /> will be done in accordance with San Joaquin APPOINTMENTS <br /> signed 2 quin County Ordi antes, <br /> riot Name A/ �'` Title/Company_ Rules and <br /> �le� P�yJ tzi <br /> TE MAP IN UNIT IVFILE-SITE ADDRESS DEPARTMENT USE ONLY Date_ / 10 j <br /> DRK PLAN DATED '�U s` m 2rf/4N S T <br />'PLICATION ACCEPTED BY �Re /9 /y 5LA ��/IJ <br />;OUT INSPECTION BY Kr.c.w1 <br /> DATE ISSUED 7 Z/-f�� <br /> STRUCTION INSPECTION BY <br /> FINAL INSPECTION BY � —AREA <br /> MMENTS/CONDITIONS: DATE DATE_ <br />:COUNTING ONLY: <br /> AID# <br /> CODES FEE INFO AMT REMITTEDFAC# <br /> p CHECK# <br /> I Q RECV'D BY <br /> $125x DATE SERVICE RO# <br /> h REQUEST PR# INVOICE <br />�v '� 37� ColiNTE2 la-7'� SR# 2009v <br /> RO# <br /> 3500 <br /> PR# <br /> 29001 <br /> WFIVER�u r� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT � ENCROACHMENT DOC .v,q <br /> Ir. IXO WELL PERMIT APP <br />