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PAHIy SAN JOAQUIN COUNTY <br /> LOP <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION <br /> ' '• 600 East Main Street, Stockton, CA 95202-3029 61 <br /> i <br /> Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:wWW.sgov.orolehd <br /> `'FOR <br /> WELL 8t BORING PERMIT APPLICATION SEP 2 0 2010 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDrATO61ggUIN <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED H�hi DS Eg LT ElIvvTM <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. ,and iJie Standards of the San Joaquin County Environmental Health Department. <br /> Site Location //313 Al 6we� `�`r-cross sir ett' 1 �t 'h+ M��'C ��City �' Zip SZ�APN 059103 040 <br /> Property j- ) r 10 ZSria #0401 MI VE -S Zi 9fZ04 Phone <br /> Owner t. e Y .`T o ti. Address ` City L p <br /> C-57 Contractor v hi 1107 Address 9 6 'P&K- C City 5 c .• Lie V- Phone , j 3Ly 77JL <br /> Consultant/Sub Cntr Kw �" eAddress LLA, -i 1. City rti Lic iPhonec yl 137fU(L� <br /> Billable Party r 1C Address 71fj Ar /i/��` City Zip J 2° Phone�'�rJ <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL(BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE 8#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC 0 OTHER <br /> _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> _O SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _OINJECTION(i.e.Air Soarae.Owns)0HAND AUGER GROUT SPECIFICATIONS <br /> _O OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No 0 Yes:Casing Die: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DgSTRUCTION METHOD- HE I LTHAT APPLY) Q� <br /> I OF WELL(S)TO BE DE��$$TROy�zD OVER-BORE DIAMETER OF INCHES TO DEPTH OF /)" FT <br /> WELL IDs: vim .L- -f [3PRESSURE GROUT TO DEPTH FT BELOW SURFACE <br /> GROUT SPECIFICATIONS n G P� ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:LJAUGERS n HOSE PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all applicable California laws. <br /> Signed � /. Title/Company <br /> r° C4 F11 'In2ILf <br /> Print Name OIJL-tLay/`I �y Dale i I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SIT AD RESS N/rl <br /> WORK PLAN DATED 4f I If 3.1 VZ.4D r l <br /> APPLICATION ACCEPTED BY _ _ DATE ISSUED_ i^� LU AREA_�F � <br /> GROUT INSPECTION BY FINAL INSPE�TI N BY DATE <br /> DESTRUCTION INSPECTION Y DATE YOI <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> .2 QJ- $122« 1 4 )7-z135` 7 ,9R# DD6 tqI <br /> Zq(2 . 1430((0 3(, u� "r (3°o <br /> ' 35 to 01 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 WELL PERMIT APP <br />