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RECEIVED <br /> R to SA14 JOAQUIN COUNTY MAY d 6 7015 <br /> T ENVIRONMENTAL HEALTH DEPARTMENF:NVIRONMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 PERMIT/CERt/jC-' GATION <br /> Telephone:(209) 468-3147 Fax (209) 468.3433 Web, www.sloov.orclleh g1NIT 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 /> Applicat on is hereby made to San Joaquin County for a permit to construct and/of insla' the work described This application is made In compliance with Sen <br /> Joaqu n County Development Title,Chapter 9.1115 3•and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 440 W.Dr.MLK Jr Blvd_ Cross Street _S Lincoln CIIylState _Slocklon CA Zo 95206 APN_165.030.03_ <br /> Property <br /> Owner Major Singh Address _2525 Stern Place �I� CdylSlate Stockton CA_Zip _95206 Phone <br /> C-57 Contractor National EWP_ Address 1'361 a)!'('-/CpJ1 41-e City/Slate i rhoujLic r _ - Pn nE S�/)'" 1�G E-1 <br /> Consultant/Sub Cntr_Stanlec_ Address _3017 Kilgore Rd,Ste 100_ Chy/State_Ranrro Co ova,CA Lic Phone 916-364-0766 <br /> Billable Party__Stantec Address 3017 Kilgore Rd Ste 100_ City/State _RanchoCordova CA Zip 95670 Phone 916-384-0708 <br /> GIS Coordinates'X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> Lq'NEW`VELL/BORING(CPT,r'^��F,HYDROPUNCH,HAND-AUGER OTHER) <br /> [pS`OIL BORINIDs_ <br /> KI <br /> [}'WELL IDs <br /> /T'1 -Z r mu.'- -7 r'h W' <br /> O OTHERIDs <br /> TYPE&//#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a�QMONI70RING ❑HOLLOW STEM DIA OF BOREHOLE IC: 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> _0 EXTRACTION Vapor?Walee 0 RAMMER?ORNEN CASING THICKNESS 5,'V,4 �/I ' TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER o <br /> _ 0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL + TRFMIE TYPE TO BE USED 0 AUGERS 0 HOSE D PIPE <br /> _0 SOIL BORING D PUSH POINT(GPI CPT) GROUT SEAL.PUMPED t3'Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _D INJECTION(1, N,saame.DeanaI DHND AUGER GROUT SPECIFICATIONS YLt'R- i'Li-"y� 7� <br /> _O OTHER Cl Or HER: -X'iiir APPROX BORING DEPTH �Otf. DTRAFFIC BOX OR ❑STOVEPIPE <br /> y� no^ASING GY<0 0 Yes Casi19 Dia A;4 Ces,19 Depen AL � - Bwtng D44- <br /> COMMENTS <br /> COMMENTS 7. S�'C� ����L�.( I'4 C� - Yw T <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: E TR ION METHOD, THAT APP <br /> #GFWELL(S)TOSE DESTROYED -� 1 OYER-BORED{ALMETEROF?t INCHESTODEPTHOF, FT <br /> [�'P <br /> WELLIDs 5_5fn =:---- / ��SMw yv 'tii'>7�U - ,�� 71U RESSURE GROUT TD DEPTH OF -�1;. FTBELOWSURFACE <br /> GROUT SPECIFICATIONS r)t' F ��lam�'JIb�^u__• 1�.T ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE T c Tn PP I'4=n M al r-coe�u cc Tgn;'Dlec ❑MUSHROOM CAP AT L3 FT1 FT BELOW SURFACE <br /> COMM S ' T � <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 all applicable CalifymlaJaw _ <br /> Signed TiVOCompany <br /> Print Name I-e) (r-t7� l - Date <br /> DEPARTMENT USE ONLY s ;5_ <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED .�1;� 2'c� �( --- <br /> APPLICATION ACCEPTED BY (/(�G'l.'VY�� DATEAREA <br /> GROUT INSPECTION BY C- FINAL INSPEQTH]N;3Y +-ailiif TE 7�y <br /> DESTRUCTION INSPECTION BY / DATE /N//� <br /> COMMENTSICONDITIONS: 7� <br /> ACCOUNTING ONLY. AID* FAC# <br /> RE CODES FEE INFO AMT REMITTED CHECK# RECVD BY DATE SERVICE PRO # INVOICE <br /> REQUEST # <br /> C�( S 130 x -- L 5 Z 3 - SRIF - Z <br /> RO k <br /> 9-x10 �( 3 0[ 3500 7--L2,2-7, <br /> PR# <br /> 29Do <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> FHnpN1 71Pana WFII PFRMIT APP <br />