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REcF'vtu <br /> JAN 0 2 2014r _ �' "� I <br /> ANVIRONMENTh {.I <br /> SAN JOAQUIN CO FfEALTH DEPARTMENT <br /> �y ENVIRONMENTAL. HEALTH DEPARTMENT of <br /> e <br /> ( kdA SITE MITIGA'1 ION <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> Telephone:(209)468-3147 Fox.,(209)468-3433 Web:vvyw.s go gietl, -- --- <br /> t.a:4¢. <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANTINVESTIGATIONS AND REMEDIATION <br /> NON_REFUNDA6LE PERMIT EXPIRES 1 YEAR FROM DAT(=1 !WLU <br /> Application is hereby made.to San.Joaquin County for a permit to construct static,install gm work described. This application is made In compliance with San <br /> Jo quin County Der to a n Chapter 9-1115.:7,and the Standards of the San.Joaquin County Environmental Health Dapertrnent. <br /> /tele � re• ;e57e �. i» w 6 f._ ciy/smte/- vvf" �i q�.... APIC._ RQw. <br /> Site Lnca4lon ;. Z.6/ZGcN..- Grass Street p....._6..................... <br /> Property <br /> Owner G�.r-/Lii?+�r✓-•r Address <br /> (/_'7�GUrr✓ // <br /> �C,rII <br /> istate :/q4.rwzaip121 Phona„<3-7 <br /> Address sG Phote � <br /> C-57 Contractor Y.s:6Y�iS• <br /> ConsultanuSub Cntr GGn,c/ Address � City/State ,__.. —Lir. _Phone J._„_ r� <br /> Billahlo Party C-75'AGdN Address __ City/State ...._ Zip__ Phone__.,__,_, <br /> GIs Coordinate,:X -•f--Y <br /> 'CgOSTRUCTION WORK TO BEE"PERFORMED; <br /> I <br /> aNEW WELL/BORING(CPT HAN AUGER,OTHERI <br /> ' �DII. <br /> �WELL IDS--.-. <br /> TYPE&#OF WELtJBOs(yC,z Lg5TT LLATION TYPE CONSTRUCTION Si FI_CATUONS <br /> i <br /> _(]MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE� ❑MULTIPLE CASINGS 0 MULTI-LEVEL WEU.CASING DIA! <br /> —I]EXTRACTION:Vsporl Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL❑PVC ❑ OTHER <br /> �] p SOI(.VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL—, TREMIE TYPE TO HE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> 4_ LSOIL.BORING y4YUsH POINT(GP/CPT) GROUT SEAL PUMPED:O Yes O No(MAXIMUM FREE FALL DEPTH IS Sg FTI <br /> __.❑INJECT ION Itsa'Ya34trtSkf!'!c1 l7 HAND AUGER"__..................._GROUT SPECIFICATIONS_,._..�__-...__ <br /> .__..❑OTHER: O OTHER:__,___.......-_APPROX,BORING DEPTH_, �S ___.(.7 BCI_rEU TRAFFIC BOX OR STOVE PIPF. <br /> ` �,;y��.,.,•� / CONDUCTOR CASING n No❑Yes:Casing DI-: ,_......_.".__Casing Depth Bating Ola: ___ <br /> V <br /> COMMENTS:fT1 �''�- <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK 70 BE PERFORMED; DESTRUCTION METHOD:ICHECKALL THAT APPLYI <br /> #OF\NELL(S)TO OE DESTROYED ❑OVER-BORE DIAMETER OF­._INCHES TO DEPTH OF_--„_„_.__,_._,Fr <br /> WELL IDs: C]PRESSURE GROUT TO DEPTH OF, FT Fr BELOW SURFACE <br /> GROUT SPECIFICATIONS_ ❑EXPLOSIVES FROM TO PT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:Cl ALICERS ❑HOSE 0 PIPE C'I MUSHROOM CAP AT Q3 FT) FT BELOW SURFACE <br /> COMMENTS --- ------ - <br /> `•..w. 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby cmlify that I have prepared if atlon and that the work will he done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and to a s. <br /> Signed .�_----” Title/GompenY <br /> Print Name ( •'� ..Jl/hii2!` .-...-.11C-tlTh� /Agil'ri/f'l"s�•/Z_” Date �l--S-✓3._.. <br /> —'' DEPARTMENT USE ONLY <br /> SITE MAP IN UNITIV FILE SITEADORESS,. ! 4lv-7 C 57• RIE 26 _----- <br /> WORK PLAN BATED _.......... _JJ,,-�CQ�-- �.-._ <br /> APPLICATION ACCEPTED BY � `-L,G✓�KUat'i "v, DATE ISSUED—Ll��3 AREA <br /> GROUT INSPECTION BY ".... __ FINAL INSPECTION BY _ DATE <br /> I <br /> DESTRUCTION INSPECTION BY .... - . ..._..___._.—_ DATE_..._ __..-_ <br /> COMMENTS/CONDITIONS: _.._ ------ -- -'-"' -'— <br /> ACCOUNT INC'ONLY: AID# FAC# .- <br /> SERVICE RO# <br /> PE CODES FEE INFO AMT REMITTED CHECKS RECVD BY _DATE REQUES ' PR* INVOICE <br /> S125x 1 1-k .79 C EL£ch„_ ,/t-7-I-gSR# _4ngc(L./3 . <br /> RO# <br /> nil tClTEF,'O A.D(ifORIZAllf NTOSIGty Pt FtMfT� � 11 L�FN(R -..,_.... <br /> U !_(/ WC — t WAIVER !L( (IAt HMf NUT <br /> WELA <br /> L i FI NIC)J'P <br /> FHD'2:]-kit 5ifs,11 <br />