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a4AUtN • SAN JOAQUIN COUNTY • <br /> .ri ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> �,'�"''• 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> j N'P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.siaov.oralehd 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. <br /> Site LocationS35 5 ti1"PR- ST Cross Street GN(AIL CH ST City Zip Ct5'L0 <br /> Property 8 3 APN f'59-320-02 <br /> Owner P� E Address -41 6E�LE ST CitySkFR FRANMLric ip otyt05 Phone <br /> C-57 Contractor PENS«'p-C Address 1239 ALICC Si, `3T!P-A City Lic 106?9'9, Phone C53e�lcfot-'�b00 <br /> ConsultanVSub Cntr Address City Lic Phone <br /> Billable Party Address 2q" OCK ¢.p. ` .��cO City I,vALNkC cls-�Zip CtyS�} Phone (�zS�2-iy-Il co <br /> GIS Coordinates:X y <br /> CONSTRUCTION WORK TO BE PERFORMED <br /> ©NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> EI/SOIL BORING IDs <br /> WELL IDs Mw - 33 <br /> ❑OTHER IDS <br /> TYPE&If OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I I MONITORING @7 HOLLOW STEM DIA.OF BOREHOLE 10 ❑MULTIPLE CASINGS❑MULTI-LEVEL <br /> WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS SANt'D 40 TYPE OF CASING: ❑STEEL [3 PVC 0 OTHER <br /> _O 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 /> _0 INJECTION(i.e Air Soarae Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH '3!T BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> / <br /> CONDUCTOR CASING t,�No 0 Yes:Casing Dia: Casing Depth: Boning Dia: <br /> COMMENTS: EL-A5E, ST-L-: ATTAcNEp MSP gi.rtJ WELL. ���.+�TRtl CT1 1 D1AG[tL>M <br /> wL-1� rtirjSTlz.il CTlCt, SPE+-AFtCATIiC <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)TO BE DESTROYED ❑OVER-BORE DIAMETER OF 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 [:1 HOSE El PIPE ❑ MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WOi DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby cert' th t I have prepared this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations an all a bl C 'fornia Laws. <br /> Signed Title/Company US !IQC. <br /> Print Name <br /> Date <br /> ( z _ EPARTME USE ONLY. L <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS 5316 S i i C <br /> WORK PLAN DATED p <br /> APPLICATION ACCEPTED BY. DATASUED Z 'L AREA <br /> GROUT INSPECTION BY _l FINAL INSPECTION BY //ter/,` DAT 1 tJ� <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: MLS S I V �� <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> ]� REQUEST PR# <br /> 9���f+t $125x t�tZJ �74SSS� (�`K- ! f L SR#00 <br /> !/[O /S µ 4 r Z X— a 00 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER___ C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />