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F ILE COPY <br /> Wo o\ <br /> SAN JOAQUIN COUNT <br /> y. ENVIRONMENTAL HEALTH DEPARTMEI <br /> I A <br /> LOP <br /> SIT I <br /> • 600 East Main Street, Stockton, CA,95202-k9�_O, <br /> Telephone: (209) 468-3454 Fax: (209) 468- 433 Web:w�. ig <br /> ov.or <br /> -q/ehd <br /> WELL & BORING PERMIT APPLICATION AUG I o 20jq <br /> FOR WELLS AND BORINGS USED FOR CONTAMINAN­INVESTIGATIONS AND REMEDIATTWjCAoUIN C <br /> ENViqONME OUNTY <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED HEAL T7-4 DE NTAL <br /> P <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install tie work described. This application is made in compliance�'Ih <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> - <br /> Site Location fJ, CA01f`0j::-'fVjA s I Cross Street Pr iF S'-F City S7 XV_F00 _Zip q S 20 q APN <br /> Property' �;75 7 C#P r?-t�.5 <br /> r' H(--'L C—r-I r*P T -z-3 1? <br /> Owner . H Address — City 6'411`rk f cr-1 A E L Zip q 5-608 Phone 19 el <br /> C-57 Contractor P(-'V-6 City"'r-UCAx7('yV Lic 41(17B"l Phone'2005 �7/-z <br /> ConsultantfSub Cntr Fb0r-"1fLL- Address 6 11141Z ','7DK.'y 2?L>4C WAY City AtJTCL_011E 6A Lic Phone q&, '7?9 S-)(5 <br /> 5 757 <br /> Billable Party OELE�J 14144M6, Address A-P rel <br /> A V-C- <br /> City e_Ajg41jiC;4 A E L__Zip '15&L6 Phone,?/6- <br /> GIS Coordinates:X <br /> C914STRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPRODE,HYDROPUNCH�HAND-AUGER,OTHER) <br /> E:]SOIL BORING IDs <br /> Ej WELL IDS <br /> D�OTHER IDs aS rz-t,J3 C-S 6 P I + 4 P'Z- <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING [I HOLLOW STEM DIAL OF BOREHOLE [I MULTIPLE CASINGS Ll MULTI-LEVEL WELL CASING DW <br /> EXTRACTION:Vapor/Water [I HAMMER/DRIVEN CASING THICKNESS '4 TPFE TYPE OF CASING: E]STEEL [I PVC El OTHER \aa <br /> SOIL VAPOR PROBE CI MUD ROTARY DEPTH OF GROUT SEAL- REMIE TYPE TO BE USED: El AUGERS E]HOSE E]PiPE <br /> _E3 SOIL BORING C1 PUSH POINT(GP/CPT) e GROUT SEAL PUMPED:El Yes XNo(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION'(i!e-AirSpargeLOzone]XHAND AUGER 5")45-;- GROUT SPECIFICATIONS <L_Uarz_�� <br /> _0 OTHER: El OTHER: APPROX.BORING DEPTH ) BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING 0 No 0 Yes:Casing Dia:_Casing Depth:_ Boring Dia: <br /> COMMENTS: _ <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DES T RUCTtON METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED Ej OVER-BORE DIAMETER OF INCHES TO DEPTH OF _FT <br /> WELL IDS: El PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ED EXPLOSIVESFRom TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:E]AUGERS [-]HOSE E]PIPE El P4USHRObM CAP AT L3 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 aSll a licable Cafflornia laws. <br /> . 11' pp <br /> Signed Title/Company .rV_7rPf/l-�_ C-04 1A1L!521N4_ _Cl VIL CN4 I/VEE1-- <br /> Print Name mleryAeC_ V_ Are-" Date i7l <br /> DEPARTMENT USE ONLY <br /> % <br /> -,A,) — <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS ,, 4A- 1 <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY., WE AREA <br /> GROUT INSPECTION BY 4. z FINAL INSPECTI P <br /> DATE I/ <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIO1 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> $122 x ?t-(q SR# 37 <br /> 00 <br /> # <br /> 3503 _-3�(0 (R3500WDC) <br /> PR# <br /> C-57 WC WAIVER C-57 LETTER OFAUTHORIZATIDN TO SIGN PERMIT v" ENCROACHMENT Doc Al <br /> EMD 29_-0107128/10I-;dtP P <br /> FILE COPYit <br />