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COPY <br /> �at``t� •. SAN JOAQUIN COUNTY ' FILE -LOP <br /> ` ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION <br /> =. 600 East Main Street, Stockton, CA 95202-3029 UNIT N <br /> Telephone:(209) 468-3454 Fax:(209) 468-3433 Web:www.siaov.oMLEhd , r <br /> C1Fo r iV <br /> ' WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION Y��J <br /> ►! �x <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 worst 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!3P;b61'AL1r09V/A ST Cross Street Pf NE CIT, cityZip APN ;05: <br /> Property. '753q <br /> y I <br /> Owner ELEN �!Gr G!NZ-7 Address �s y YrSTA fit. City S r�v�nz��p 9582 7 Phone 9/�C y�4� <br /> C57 Contractor5;4wFf411 Address?3G 5- J(IIG� [?I'• City Lic 63&3S7Phone 209 y65 87, <br /> Consultant/SubCntr ^rt94-L&�rZ. Address g44YZ ! .�e� [�L,� W'ICity AN::[- Lic4f5770Phone 7/(0 7z9-SSP <br /> Billable Party FOD7rf ILL LV40. Address I( City it Zip 9E94`3 Phone 1i <br /> GIS Coordinates:X Y --rj-x-29 <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&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> __,_,❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS(❑MULTI-LEVEL WELL CASING DIA: kv <br /> —❑EXTRACTION:Vaporl Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP!CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —❑INJECTION 0.s.Air soaroa.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE ` <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: y` <br /> COMMENTS: • <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> 7 DESTRUCTION WORK TO BE PERFORMED: DES§TR_ UCTION METHOD:ICHECK ALL THAT APPLYI ,3 �1_�#OF WELL(S)TO BE DESTROYED Ig OVER-BORE DIAMETER oF1z8 f I SINCHES TO DEPrH OF 5-BSF-r <br /> WELL IDs: M w- (5,,h>, ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> - GROUT SPECIFICATIONS '5r L42jx.( 14,01 5r l- ❑EXPLOSIVES FRom TO FT BELOW SURFACE <br /> TREMIE TYPE TO�E USED:❑AU ERS ❑HOSEPIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS /5 O,9, /-yZ M W-7- ye�-6V jPV F2, e- <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 appli blee/CBr mia laws. <br /> Signed Title/Cornpany "f'4 C irr 1 <br /> Print Name Date J <br /> DEPARTMENT USE ONLYLbP- <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED • I p <br /> APPLICATION ACCEPTED BY DAREA p <br /> GROUT INSPECTION BY �y,� r )FINAL INSPECTION 8 �`OAT <br /> DESTRUCTION INSPECTION BY L. r+1 I" DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMrrTED CHECK# RECV•O BY DATE SERVICE RO# INVOICE <br /> REQUEST PR* <br /> 350 •- /02.-. G'u� Q/�/� SR# Ofo3 8 <br /> 350 375. RO# <br /> l 3500 6 0 <br /> EHO729-01 o7f281t[7 C WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERrj ECIRPTT DOCS /V APP <br />