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P° tN c 0 SAN JOAQUIN COUNTY IV FILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> Q a <br /> 0 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> d• P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.s' ov.or T <br /> 9(IFOR�` <br /> WELL & BORING PERMIT APPLICATION '^A' <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIA&I 9 2012 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENViq <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application i ��bhTu San <br /> Joaquin County Development Title,Chapter 9-1115.3,agd the Standards of they an Joaquin County Environmental Health De .T/S�••171. 7a <br /> f ,) A.4. <br /> Site Location 6A'f.L�1)QCdoo,!k//r/IK.Cross Street .T{I�rrt'�'Oy7_�4 city Zip 952/3' APN Us5_3r` C/ <br /> OwPronert,5 1/b'e *'4n/�/b— Address (�Yat 444 / -6kt city Lrt ` Zip Phone <br /> C-57Contractor lgPcaz� Address 1{63' Grf..o... On City 5ydR, _ Lic 6767&7 Phone fzo9)y(g.87/i <br /> Consultant/Sub Cntr %Ae Su�j:Address 9y7 /7r�iuilww /j/. 5.,?t-4 City v^•/ Lic Phone ff7o)i7�-Yrs <br /> Billable Party s.." y.c. Address r /7<<e .<. r"-4 e`{ City /„a�Zip ?5,9y? Phone <br /> C37o1271-Y-;oo <br /> GIS Coordinates:X . I I Y 2-1 - R <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: <br /> ❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL O PVC ❑ OTHER <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS ❑HOSE ❑PIPE <br /> —0 SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ❑INJECTION(i.e.Alr Sparge ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: ❑OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR ❑STOVE PIPE (� <br /> CONDUCTOR CASING[INo❑Yes:Casing Dia: Casing Depth: Boring Dia: a <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TOB DESTROYED ®OVER-BORE DIAMETER OF Q INCHES TO DEPTHOF O Ff\ <br /> WELL IDs: HL.-f[ Al HG,- [ ®PRESSURE GROUT TO DEPTH OF L 'L FT BELOW SURFACE <br /> GROUT SPECIFICATIONS r ®EXPLOSIVES FROM ;Q TO /f6 FT BELOW SURFACE <br /> TREMIE TYPE TO BE U ED:®AUGERS SE U PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS ,9� y( n /SD r � ��. i <br /> va666 60.,4 y oa �— e <br /> 5 WORKING DAYS IfOTICE 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@pII"ap/plicable California Laws. <br /> Signed !�f/•✓ Title/Company S-xllr 3'."e <br /> Print Name AA� li, . . Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS CU. <br /> WORK PLAN DATED - 7 d"10111P <br /> APPLICATION ACCEPTED BY DATE ISSUE <br /> GROUT INSPECTION BY CO3ffV1ATVnFINAL INSPECTION BY 1.(t1// TE -I <br /> DESTRUCTION INSPECTION BY DATE�,•Na(2 <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV' BY DATE SERVICE RO# INVOICE <br /> Y 7 REQUEST nPR# <br /> 125 x sd / SR# <br /> y�� 3 3�s <br /> 25 _ P9 0 SS G <br /> C-57 WC V WAIVER C57 LETTER OF AUTHORIZATION TO SIGN T I '"8 HMENT DOC <br />