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aP4Hl. , SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> e, a SITE MITIGATION <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> lehd <br /> c . Telephone:(209)468-3454 Fax:(209) 468-3433 Web:wwwsiaov.Org— <br /> < FORS <br /> WELL & BORING PERMIT APPLICATION �al'R a 201: <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED pr � �eV✓S�r� r <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, n an <br /> Joaquin County Development Title,Chapter 9.1115.3,and the Standards of the San Joaquin County Environmental Health Department. _ <br /> 'r y wg9r Cross Sheet (i�1T`/Sb.t��W-`j• �CF+tCity SI -r n Zip aSWG APN ci74107�9U7`/°) <br /> Site Location <br /> Property <br /> e < � �cnu IBJ Cowc'>-`-1 Address 1Q� n e µ��'('� � City 5Y°+k'� Zip 9SZ05 Phone 721- <br /> Owner !; <br /> OwnC-57 rContractor •1 R:�1 O Address liROG htrL t QZFV_ DR City STa "o'� L1024g0L( Phone 7M -'' 1-7760 <br /> Consultant/Sub Cntr )CLEI7.��' AElLAddress 'ZZ)b( k`xfh-A�Pop T- 2Jbrtity 5^7X,CTc^ Lic `/ S S/jPnone '7�) -44$13yf <br /> Billable Party kl r%-,U FG7J07' - Address ?x0l 426k-A-KPOE RO 10) City 5/­iDC1-rU- Zip­§LZQ& Phone 7,9-$`vl�-1 /S <br /> GIS Coordinates:X'-I a112ZLI v Y-3201052. <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEWWELLMORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> _ <br /> OIL BORING IDs �- <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS' <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE """��0)MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> —[I <br /> EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS STYPE OF CASING: ❑STEEL 0 PVC 0 OTHER <br /> _O SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL O —%. TREMIE TYPE TO BE USED: 0 AUGERS ❑HOSE 0 PIPE <br /> [$SOIL BORING tit PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes'oNo(MAXIMUM FREE FALL is 30 FTI <br /> _O INJECTION ii.e.Air Sparge.Ozone)0 HAND AUGER GROUT SPECIFICATIONS <br /> —[:]OTHER:_ ElOTHER: F� <br /> APPROX.BORING DEPTH ' O BOLTED TRAFFIC BOX OR ❑STOVEPIPE <br /> CONDUCTOR CASING IM No 0 Yes:Casing Die: Casing Depth:_ Boring Dla:__ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD rcHECK ALL THAT APPLY) <br /> �#OF W ELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPT FT <br /> El PRESSURE GROUT TO DEPTH OF BELOW SURFACE <br /> WELL IDs: ❑EXPLOSIVES FROM T BELOW SURFACE <br /> GROUT SPECIFICATIONS <br /> TREMIE TYPE TO BE USED:❑AUGERS [I HOSE [I PIPE Li MUSHROOM CAP AT L3 FT) _TO FT <br /> 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 applicati n a that t e wo will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws <br /> SignedC itle/Company F�/D�Ou_IOrJryS�ryL �CLFvVFfL12-Print Name / � G ) _T Date <br /> 'q,,� DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS CLJ &-p1 1-I'DLT (7k)t,< <br /> WORK PLAN DATED f 'SIL 2 ZO! 3 <br /> APPLICATION ACCEPTED BY .-I DATE <br /> GROUT INSPECTION BY FINAL INSPECTION BY lfB-`-73 <br /> DESTRUCTION INSPECTION BY DATE APH U 2 2013 <br /> COM M ENTSICON DITI ONS: <br /> SAN JOAQUIN COUNTY <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERV[I1 _p N19I 1 <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D 8Y DATE REQUEST PR <br /> b S <br /> $1zs X 1362-S 0c>tAVTER sR# <br /> _ RO' <br /> 29 3 1� 3500 <br /> PR# 65 3 "► d� <br /> 2900 <br /> C-57 WC / WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMITENCROACHMENT DOC ' <br />