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RECEU y <br /> SAN .JOAQUIN COUNTY ''p- u <br /> F1L� <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> IRON E 10 <br /> 1868 East Hazelton Avenue, Stockton,CA 95205- ERMIT(SERVICE%NIT IV <br /> Telephone:(209)468-3454 Fax: (209)468-3433 Web:www.s0ciov.orlq/eh—d <br /> d WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> the work <br /> Joaquin'County Dave opment Title,made to San IChapte Countyuin 9.115.3,a d hefor a t to construct and/or Sta dards of the San Joaiquin County Environmental iapplication <br /> Departments compliance with San <br /> oo M, WasA,nB7`vn CI Stoa/r7`on CRZi !;A15 APN �'90x020 <br /> Site Locatlon2 Wn 4nln AVB. Cross Street � ty P3 . <br /> Property <br /> Owner 5-'X co'-'O. Address 1351S /3,,A tt. Coes° 1'/ouCity LhAnfo*/e NGzipgg'PZF•¢ Phone 0r/' �'feZ-HNjO <br /> C-57 Contractor La ScA de DnT//int Address I.ZO Sower 23ro� Sy: City /�ie/tm04d C9 Lic 7391)C' Phone <br /> Consultant/Sub Cntr! Wj %c;'T'Addrsss 3322 fowl^ Ton /tel Cilyt4aia•r./6 e4 Lic M4 Phone 916^9/8-193 f1 <br /> Billable Party MWHamenitaf Tge Address3321 /'owe^3%rn 1?d City 344^Anry1e<4 zip9543a6 Phone 9/6-H/8-,4352 <br /> GIs Coordinates:x 635008.Y9 Y a•1;zs097.1/2 4ItW.' <br /> R0WnCS/ <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> SOIL BORING IDs S B s �,. 5 /O s f/� '�/•3 5 -f� S^)5 5- 16 , .S' /7-4 <br /> WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:I'd <br /> _❑EXTRACTION:Vapor/Water [IHAMMER]DRIVEN CASING THICKNESS IV-4 TYPE OF CASING: [I STEEL [I PVC IN OTHER fLt,4 <br /> _I]SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEALl BQ�TREMIE TYPE TO BE USED: (AUGERS ❑HOSE ❑PIPE <br /> L0- SOIL BORING 'K PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION^ ^Je Dnet0 HAND AUGER GROUT SPECIFICATIONS PO� f/Q-dd Tipe4ZTl 17C�At�` �emPgf <br /> _[]OTHER: %OTHER.-RoyLe,e APPROX.BORING DEPTH 7190 -5� ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> SOnr 1 <br /> CONDUCTOR CAST N.0❑Yes:Casing Dia: Casing Depth:_Bodng Dla:__ <br /> COMMENTS: I A64 fjo 'nr Wi// da HSe[✓ ya Tn 'P'74 <br /> a Remedul noe✓ef'And then ahRndonedf M <br /> ncfi ` <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS cemenf <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) Cy/1011 <br /> Lo #OF W EL44(S)TO SE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: S-6 ThnaOs /� S^•/ �j PRESSURE GROUT TO DEPTH OF 1 INCHES FT BELOW SURFACE <br /> GROUT SPECIFICATION n EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:9 AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5W IRKING 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 applicable California Laws. <br /> �noiCaf �n4yP� / 9r/ G1inBn,C45 <br /> Signed �� �� !� Title/Company —e <br /> ' <br /> Print Name Ear G 3• O ft a Date_ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS <br /> WORK PLAN DATED •Z -1 Z <br /> APPLICATION ACCEPTED BY— (,qo rrKu.� D AREA /,.� �4�7 <br /> GROUT INSPECTION BY FINAL INSPECTION B DATE Os.J1041 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMME NTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# INVOICE <br /> R90 g125X / fLS AEcr &4t C4 c,—t ;16-2 SR#crit 5 R70 <br /> Roo 3�5 37s �04?C)7— Rsoo <br /> PR# <br /> 2900 �lCJO <br /> 5-57 v WC ; WAIVER N/a C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC AL& <br />