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y.•;m�:•, SAN J1OAQUDN-OOUNYY _ <br /> ENVIRONMENTAL HEALTH DEPARTMENT � <br /> • 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION. <br /> Telephone:(209)468.3464 Fax:(209)468-3433 Web:UVWW.sjMoy.oM/ehd - UNIT IV <br /> WELL & BORING PERMIT APPLICATION QPR 'J ?Ok ', <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 c'r pii' ce win San <br /> Joaquin County Development Tide,Chapter 9-115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> �ro w 1RCX tJ <br /> Site Location �"�1%� .1 Cross Street E=1-'T`fSbJxt1 f" PaO City Szc.ktvn Zip `�ISZOC APN 92HtOf 7a 4-97-l 7) <br /> Property <br /> Owner _S•arJ �e.Ac 1/I'J C&rN -I Address i R1 0 P. 14.92C(7an Aix City Zip-9 ti Phone 20Di-NGY-35'j-/r <br /> C-57 Contractor )41,j olzAitui Address .oaf rr. DUCA C-Mr.EU J)L City 5T0d0 01 Lic AQjrsy Phone 201-'40-7784 <br /> Consultant/Sub Cntr C/J=Lu F'- b-0zAddress Z-'Z( 6;h-AlrogiLl' Al b'ACity SZL/C Ton LiejtLj: Phone 'Z09 -ANS iy <br /> Billable Party lu c-t t)rcu*w- Address 2 OI City 51 Zip 9 Z06 Phone e2 �f <br /> GIs Coordinates: V'L201052 <br /> O STRU TION WORK TO BE PERFORMED: <br /> ❑NEW W LLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> NEW <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> _TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS' <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> —0 EXTRACTION:Vapor/water D HAMMER/DRNEN CASING THICKNESS IVA, TYPE OF CASING: O STEEL ❑PVC O OTHER <br /> _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 0 :-f; TREMIE TYPE TO BE USED: [ AUGERS [ HOSE ❑PIPE <br /> -qQ1 SOIL BORING EL PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes''No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION(LeAr Soeme.oroml❑HAND AUGER GROUT SPECIFICATIONS � Z Ply C4F'A4511Q- <br /> _O OTHER: ❑OTHER: APPROX.BORING DEPTH BOLTED 6J i BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING 9 No f]Yes:Casing Die: Casing Depth:_ Boring Die: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APpLYI <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPT Ft: FT <br /> WEE IDs: -- ❑PRESSURE GROUT TO DEPTH OF BELOW SURFACE <br /> GROUT SPECIFICATIONS [:1EXPLOSIVES FROM io FT eELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERS HOSE PIPE [3 MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS .. ,._.y._, <br /> 5 WORKING DAYS NOTICE REOUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this applicatl In a that a we will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws <br /> Signed / 10e/Company O rdFeX.`rv:.>,L <br /> ��GG♦="irVF.�LLp <br /> Print Name s1J, +.TJ Cr Date <br /> �Q,,,� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS BCD l 7(0- <br /> ,JrC.T' {7RIUC <br /> WORK PLAN DATED ITf iz ,Z ZO/ 3 <br /> APPLICATION ACCEPTED BY J DATE ISSUED p��driFa..l�.Q4 <br /> GROUT INSPECTION BY FINAL INSPECTION BY_ r f <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: _ 0 2, 201f <br /> ACCOUNTING ONLY: AID# FAC 9SAN JOAQUIN_COUN7y <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR <br /> $125x <br /> -P Ia01Nr1��- <br /> 96 5 $125X 1 J-.-, /3g2S eoCt/U752 �/'z-/3 SRSIYVWVS/ A <br /> ROI <br /> 3500 <br /> PR 0 <br /> 2989 U <br /> G57 WC , WAIVER !V A/C57 LETTER OF AUTHORIZATION TO SIGN PERMITr L ENCROACHMENT DOC <br />