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e4NI. - SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> F Telephone: (209) 4684464 Fax: (209) 468-3433 Web: www.sigov.org/ehd 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 fora pennil to construct arldlor install the work described. This appiiealion 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 Depannlenl. <br /> Site Location Cj,&4 +u . CmssStreet S. Gfa . S) _ city $4cek4ov Zip 4SZ46 APN 142343x9 <br /> Property <br /> owner _ Y1u � w � 92i ZN. , Address 441 t._ U .. , CIty Stsekd-oZIP °15206 Pnone(Zri) 2� 1 - ZS }SS <br /> C-67 Contractor Tt5h Nv Evir" $hCr;ygddress 3115 Laau 3 AriyL city P.'k . la (wlsa Lic %19S4kphonclell(,1639'S56y <br /> Consultant(Sub Cntr tx EvrtirsFuL. Address 11244 Pvi kts. �+ City (: 10. Riw, Uc Phone(g116) 851 -01?y <br /> Billable Party cx EY41vakjL1% T, e, Address '—� �' city zip °t5G?0 Phone(%alS I -0l7• Y <br /> GIS Coordinates: X 37, 91/o78Gjr90 Y - 121, 279 5s?Yjo73 <br /> CONSTRUCTION WORK TO BE PERFORMED' <br /> U NEW I ELLBORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTTER) <br /> ❑ SOIL BORING IDs <br /> U WELL IDs <br /> U OTHER IDs <br /> TYPE & # OFWELLBORING INSTALLATIORTYPE CONSTRUCTION SPECIFICATIONS <br /> —U MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI EVEL WcLL CASING DIA <br /> ._[I EXTRACTION: Vaped Water ❑ HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING. ❑ STEEL El PVC ❑ OTHER _ <br /> _Ei SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br /> _[] SOIL BORING U PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yea [7 No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _17] INJECTION de ar nuaroa Omnnt ❑ HAND AUGER GROUT SP£CIFICATONS <br /> _O OTHER: ❑ OTHER: APPROX_ BORING DEPTH ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING EINo E3 Yet: Gating Die: Casing Depth: _ Boring ria' <br /> - <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTIot METHOD: (CHEre Tar P Lr <br /> �_# oFVJEu_ S) TonE DEsrROYED OVER-BORE DIAMETER or: Ii INC HESTODEPTHOF$0J —FH-TS S' <br /> WELL IDs: _ W - t , MY.s - 4 Iw -S ❑ PRESSURE GROUTTO DEPTH OF T '0 '21 'Pr' BELOW SURFACE <br /> GROUT SPECIFICATION ❑ FXPLOSNES FROM To Fr BELOW SURFACE <br /> CO M E TYPE TO BE USED: AUGERS HOSE IPE U MUSHROOM CAP AT (>3 FT) FT BELOW SURFACE <br /> COMMENTS l� <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 accordanco with San Joaquln County Ordinances, Rules and ` \ <br /> Regulations, and B1Lapplic California laws. <br /> Signed �G ) TiOetcompany2, _ of r,. ,u, / t E c< .lam Z <br /> Pro[ Name rinL� drk Crt - Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE - SITEADDRESS LoP r- I�x — Tf9 C- Ckr.i-te> LJu.7 <br /> WORK PLAN DATED /O If 2110 <br /> APPLICATION ACCEPTED BY /�Giy I / AREA 1V;0 <br /> GROUT INSPECTION BY Y � �'l'AYVam �.�f?M� 10 ' 7. 1 - / D FINAL INSPECTION DATE 11V;0 <br /> DATE <br /> DESTRUCTION INSPECTION BY � A�'?/V d � � r t7K r DATE / �C,-/_ _ <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID # FAC # <br /> PE CODES FEEINFO AMT REMITTED CHECK # RECV'O BYDATE SERVICE RO * INVOICE <br /> REQUEST PR # <br /> 3502 s 122X 3 -t3ao 136 Z6 a0l SRt O� 127 <br /> 3So3 366 RO 0253 <br /> PR * <br /> 2900 <br /> C-57 ✓ WC WAIVER G57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29.131 07128!10 WELL PERMIT APP <br />