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o44Vly <br /> CASAN JOAQUIN COUNTY , <br /> ONMENTAL HEALTH DEPARTA \I <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> �4 Il 'p SITE MITIGATION <br /> /FORS Telephone: (209) 468-3147 Fax-' (209) 468-3433 Web:wwln/.sLgOv ora/ehrl <br /> UNIT IV <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <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 in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department, <br /> Site Location�� 7-dNaICl ev <br /> Property Cross Street (i. I C71�T f- City/State `7TD^ Tfu <br /> Owner /i/VIC -- ----"Tn,^�r�AddressZoOl G (iG+W57D•vG5> /} GctrNrx,�kzip GS2-a6 APN /�t •a9a•13 <br /> C-57 Contractor ri//� City/State p— <br /> Address D -12 <br /> ZIP 1 ND Phone (( <br /> Consultant/Sub Cntr /1/G_ 1 fur' `s*ref City/State GhSale/rowl 93,py/O Phone 5//a 5' <br /> Address _ 23S�r/�Qpu_ y_ jlfj_,fr= City/State NT <br /> Billable Party ry}yr(,r Lic( r �Y Phone�7-$2; <br /> Address City/State 0� <br /> GIS Coordinates:X y Zip Phone <br /> 5(<7 -Izl, S Mw_6 itT: 3`?y4s3o6°, lorv; .z.l . ZJsoNes° � <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW <br /> ❑SOIL BORING IDs(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> 29 N <br /> WELL IDs <br /> ❑OTHER D. <br /> TYPE&#OF WELUBORING INSTALL— CONSTRUCTION SPECIFICATIONS <br /> 1 <br /> a�C�MONITORING ],'HOLLOW STEM i, <br /> _❑EXTRACTION:Vapor/Water DIA.OF BOREHOLE S^ , ❑MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA: <br /> ❑HAMMER/ORIVEN CASING THICKNESS �lt... C(tJ <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 'Z( TYPE OF CASING: ❑STEEL <br /> B,If' C E] OTHER <br /> _0 SOIL BORING [I PUSH POINT GP/CP � TREMIE TYPE TO BE USED: (]AUGERS <br /> _❑INJECTION( e A Spar,.. ( T) SEAL PUMPED:F yes No(MAXIMUM FREE FALL DEPTH S 30 FT) 4A HOSE— <br /> GROUT PIPE� <br /> El HAND AUGER GROUT SPECIFICATIONS_t YID I) <br /> _O OTHER:- El OTHER: FDL Iq0 1 iZL yr 1 U <br /> Ile <br /> APPROX.BORING DEPTH <br /> COMMENTS: <br /> CONDUCTOR CASING No Yes:CasingDia: BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> Casing Depth:� Boning 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 AP <br /> WELL IDs: TER OF pL <br /> GROUTS PECIFICATIONS ❑OVER-BORE DIAME❑ PRESSURE GROUT TO DEPTH DF INCHES TO DEPTH OF FT <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑ PIPE ❑EXPLOSIVES FROM �FT BELOW SURFACE <br /> COMMENTS E0MUSHROOM CAP AT > TO FT BELOW SURFACE <br /> L3 FT)-F.I.__SURFACE <br /> WORKI <br /> 5 gYS NOTICE REQUIRED (AFTER PER ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certif4th a prep is application nd that the work will be done in accordance with San Joaquin County Ordi aZcel Ruies and <br /> Regulations,alicabl alifornIs la sSignedra Print Name /t/ a Title/Company 1 F•(3J�:S���j 6t S�j <br /> � <br /> � <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS ��,`Ly S <br /> DEPARTMENT USE ONLY Date-26ln1n/c.J <br /> WORK PLAN DATED 19 �/i �WIF R.r EARN 57- <br /> - S7t��(ra/tJ <br /> APPLICATION ACCEPTED BY f <br /> GROUT INSPECTION BY DATE ISSUED7!�AREA <br /> DESTRUCTION INSPECTION BY FINAL INSPECTION BY <br /> COMMENTS/CONDITIONS: <br /> DATE DATE <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO FAC# <br /> AMT REMITTED CHECK# RECV'D BY SERVICE RO# <br /> lil ( DATE REQUEST pR# INVOICE <br /> $125x <br /> 2�fo 3 37 �liN7e2 /o iy SR# 2CJl <br /> RO# <br /> 3500) <br /> C-575/09/7Pill <br /> 112 WC WAIVER�� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT (2900 <br /> END 29-01 <br /> ENCROACHMENT DOC .vq <br /> WELL PERMITAPP <br />