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SAN JOAQUIN COUNTY <br /> o EW, tONMENTAL HEALT DEPARTM ,r/OP <br /> LOP <br /> { ITE MITIGATION , <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> Telephone: (209) 468-3454 Fax:(209) 468 3433 Web:wwwsgov.orglehd <br /> �fi=••ate nFF• <br /> WELL & BORING PERMIT APPLICATION ��I�lit'rE <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 3 YFAR 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 compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location, �20 N'CAL i F Cross Street F! City 4'rO; Zip 2� �` APN <br /> Property <br /> Owner v' P,�,�fl TAMS ' i Address 7320 N• C,�:_`- �T City 'dG'=`T �i•. Zip �ti'Phone��� L'�o Cp <br /> C-57 Contractor{�?rGl�a)ON tt�,�zl� dress �jfc� tiG r l `�I'; City " 'rJl ' Lic q54 � Phone: S!0'3 <br /> Consultant/Sub Cntr ion r r 1`L �G, Address 8L+L4z s'O �'�✓� ' City NomLic G S• 707 Phone':'i'7," Ci y l -7f� <br /> =:.�P <br /> Billable Party Address I City 1! Zip S8 4 3 Phone <br /> GIS Coordinates:X :5-7. `l7�':71 Y I Z ct0 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL Ids <br /> ❑OTHER!Ds <br /> TYPE&#OF WELLlBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ' <br /> _❑EXTRACTION:Vaporl Water ©HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _L]SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ©HOSE ❑PIPE N <br /> _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL.PUMPED:El Yes ❑No(MAXIMUM FREE FALL DEPTH IS 36 FT) <br /> r❑INJECTION(i-e Air snarae ozone)❑HAND AUGER GROUT SPECIFICATION <br /> _©OTHER: ❑OTHER: APPROX-BORING DEPTH LI BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS A13REEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THATAPPLY <br /> #OF WELL(S)TO BE DESTROYED iff <br /> DYER-BORE DIAMETER OF 8 INCHES TO DEPTH OF .3© FT <br /> WELL IDS: M w-o i A.i I ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS S-ro loscjj P70 To `ami'' 1-1E14 i ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED ❑ AUG RS ❑HOSE PIPE ❑ MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT IS UANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all <br /> app/li�blle�California laws. <br /> Signed �✓�' /•%GC ��— TitlelGompany���'iL (jLr 1Nj�,�jf f/�� t/V I, <br /> Print Name 1*11LIZA EL ��� `� Date T, lZ--l <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS Z51.5 t <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DAT AREA r��Q <br /> 0'%sXW'';ern •2­,aw -w a-u <br /> GROUT INSPECTION BY FINAL_114SPECTION BY — DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC <br /> PE CODES FEE INFO AMT REMITTED CHECK# REC 'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 3507- $ 12Cx Z_ 250 - 33 SR#D(v f%3 <br /> 55b3 3T5. RO# <br /> 35001 <br /> bZ'Spope <br /> C-57 ✓ WC WAIVER C-57 LETTER OF AUTHORIT IG E DOC <br /> EHD 29-01 07128110 - ,WELL PERp4{T APP <br />