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cu7T <br /> • n. c SAN JOAQUIN COUNTY <br /> >:•fit'., <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> b •`. 1868 East Hazelton Avenue,Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.siaov.orn/eh11 UNIT IV <br /> 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 /> 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. 1 <br /> Site Location �00�. �1�1Yfe,, Amoss Street W�^tn� D City 1'C Zip 5-z)5 APN <br /> PropertysaX C �� G v p p "Z$L�'�t Phone `T'+3i <br /> ! Owner ..]9 m�t�•:� r\ Address X35 5 a� ah TC City \ Zi <br /> C-57 Contractor to Address UI SO rJ e. �a°" City r A« Oc 8t� � <br /> S 11,S Phone 9ZS"-.�13 -i4''D <br /> r <br /> Consultant/Subcntr Address �nS _ �- City r. �S Lic Phone <br /> Billable Party �v.�ati Address Tw; �Y S�. city �_Zip ZD phone �.9 CLQ <br /> GIS Coordinates:X J•2�° 1 ' I� T/Y . D S$1-3%1 N <br /> C NSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER.OTHER) <br /> ❑SOIL BORING IDs <br /> WELL IDs �J <br /> 70 OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPPEC¢flCATIONS ,1 <br /> Z (MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1-4/3 O MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Z'\t\• <br /> _0 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS ScV- a D TYPE OF CASING: ❑STEEL 36 PVC O OTHER <br /> _�:]SOIL VAPOR PROBE 'AMUD ROTARY DEPTH OF GROUT SEAL It-I l TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE 11 PIPE <br /> —❑INJECTIONIL BORING f e ar So,,,.omsel/]HAND AUGER GROUT <br /> CPT) GROUT SPEC C3 PUSH POINT FGROUT SEAL I�CATEpONS Yea O No(MAXI�M•UM P�REEr `FALL DEPT;IS 30 FT) <br /> � <br /> hrR <br /> _[3 OTHER: [3OTHER: APPROX.BORING DEPaT,H1 X-0 DJBOLTED TRAFFIC BOX OR i]STOVE PIPE <br /> \ CONDUCTOR P <br /> SING NO,O Yes:Casing Die: Casing Depth_Boring DW:_ <br /> COMMENTS: Ws � Z wt��1 Sc r< ,1 1V -�' xis�� Mss 1Do •r�+� ��b �� ��... ltthv- �o ISMS. <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS 1 <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OFWELL(S)TOBE DESTROYED ❑OVER-BOREDIAMETEROF INCHES TO DEPTH OF FT <br /> WELL IDS: ❑PRESSURE GROUT To DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ATL3 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 a plIcaple Calif rola Laws. j� ) <br /> Signed Title/Company /��I,eU� A°`P�K <br /> Print Name �"YeVevt ��LaY Dale <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS 1530 ry, 15 n•G 41 <br /> WORK PLAN DATED _.Z -1 2 <br /> APPLICATION ACCEPTED BY `]o alrCrA niL DATE I ZTW—�/6—� <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY <br /> COMMENTSICONDITIONS: L 123 If W <br /> IAA.�o AD i <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE _-RO p INVOICE <br /> EOUEST PR <br /> ),901 81251 E4d- _ 1-1 SR#5QWGS/ <br /> 290 -37 34Zoq (3500 <br /> PR`#- <br /> z90o <br /> C-57 1, WC i. WAIVER _/J/(� C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOCS <br /> In/�-t. <br />