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SAN JOAQUIN COUNTY <br /> ' z.• �� ' ENVIRONMENTAL HEALTH DEPARTMENT LOP -- <br /> ' 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> I. ..: Telephone;(209) 468.3454 Fax: (209) 468.3433 Web:y".ggov.ora/ehd 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 /> Appllcallon Is hereby made to San Joaquin County for a permit to construct and/or install the work deeerlbed. This applleatlon Is made In compllence with San <br /> Joaquin County Development Title,Chapter a-1115.3,and the Standards of the San Joaquin County Environmental Health Department, <br /> Site Loca' Property lion Z9 EGl9F t0 S} Cross Street -n.L_UV_ City Zip 1937U APN 90*V I.01y <br /> owner-_(,�Qt�.Y1 PQGtl1'G Qtil1fGq'�gddreas 94SIh�ififli0tt$fl 5��I(t')City aRSICVI(S,E Zip953H_' Phono Ib' •s)$ <br /> C-e7 Controetor PeneCofe Address 113Y Ah2C SF 5 ihCA City W ODAIaENA UC'7010 I'l Phone S!o' P d <br /> ConsultanNSub yCnlrA1 DIS Address I RID R _Ic�3�iDl(y UO • Phone9lb-481as 1g� <br /> ' BIIIablePartyl)QC�tS US Address 1��,f bW Coy Ip 80121 Phone — <br /> 018 Coordinates:X 37, 737 Y <br /> ' CONSTRUCTION WORK TO BE PERFORMED• <br /> ❑NEW WELLIBORING(CPT.GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ' ❑OTHER IDs <br /> TYPE B#01125LELUBORING INSTALLAEONTYPE CONSTRUCTION SPECIFICATIONS <br /> _0 MONITORING ❑HOLLOW STEM DIA OF BOREHOLE_ 11 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING CIA_ <br /> _O EXTRACTION:vapor!Water Cl HAMMER/ORIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER , <br /> ' _0 SOIL VAPOR PROBE 13MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE ❑pipe <br /> _0 SOIL BORING 0 PUSH POINT(OP/CPT) GROUT SEAL PUMPED:0 Yee 0 No(MAXIMUM FREE FALL DEPTH IS 30 FTI <br /> _0 INJECTION n. All Same Ovinal 0 HAND AUGER GROUT SPECIFICATIONS I <br /> ' _O OTHER: ❑OTHER: APPROX BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING 0 No Cl Yee:Cuing Dle: Cuing Depth:_Bodng Dir._ <br /> ' NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:ICHECKau rHnT nPPLVI �L_��"�� <br /> WELLi s:WELL(S)TO BE DESTROYEDQA i'Ctb�R L79OVER-BORE DIAMETER oFaaXnomNCIIES TO DEPTH OF.NrTAOI <br /> WELL IDS: 0. 0 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS wit GCYVVNI'o O EXPLOSIVES FROM TO FT BELOW SURFACE <br /> ' TREMIE TYPE TO BE t1SED:U AUGERS U HOSE PIPE 0 MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> B WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> ' I hereby eertl that I have pr er d this application and that the work will be done In accordance with Sen Joaquin County Ordinances,Rules and <br /> Regulatlo a, nd all appllcab I C Ilfornla Laws. --- <br /> Tltle/Company erod e ci S'c,4FA H.3'/' //I/L <br /> Print Name �.ott J�nc(4m�n Dole_ /Ir-•(-po// <br /> ' 1 DEPARTMENT USE ONLY <br /> 7 <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS [ .20 C, G S� <br /> WORKPLAN DATED <br /> ' APPLICATION ACCEPTED BY _ J, yo/9X"01 DATE ISSUED _l): /O-lf AREA 16 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> ' COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PECODES FEE INFO AMTREMITTED CHECK# RECV'D BY DATE SERVICE NO INVOICE <br /> agoz REQUEST+ PR*7 il2sxl")l(� SR# �pJ Cj <br /> 11(ZSR= `l�f � L'�2 GI- -ll 3aDoo <br /> 1 X903 oo c�1 o y9 <br /> C•57_�_ WC -,WAIVER 57 CLETTER OF AUTHORIZATION TO SIGN PERMIT 0011 HMENT DOC <br />