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°Pa"'! SAN .JOAQUIN COUNTY <br /> c <br /> EQNMENTALHEALTH DEPARTPNT LOP <br /> '• 600 East Main Street,'Stockton, CA 95202-3029 SITE MITIGATION <br /> Telephone:(209) 468-3454 Fax: (209) 468-3433 Web:Www.s• ov.or leh UNIT IV <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIOAY 17 2 032 <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 114R�QFbI V L"ifal TfH <br /> Joaquin County Development.Title,Chapter 9-i 1.15,3,and the Standards of the San Joaquin County Environmental Health DepartmenPERMIT/SERVICES <br /> Site Location 4&i&06,for w opi ojXross Street {/v,ree. City L�7r Zip (�� i <br /> Property _ _ v APN <br /> Owner s Address ULjq City T,o"rryn7 Zip Alc�­z p t Phone 101 948'365"4 <br /> C-57 Contractor (��a��fla�S,�„i4 Address H0 W �-O, City Lie Phone�Zsz iy tfsoo <br /> ConsultarttlSub Cntr(j* <br /> Address 11q40 „ City 'e>O --vq- Lic Phone 70- <br /> Billable Party Address City Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED <br /> ❑ NEW WELLIBORING(CPT,GEOPROBE,'HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> []WELL IDs <br /> ❑'OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE s CONSTRUCTION SPECIFICATIONS' <br /> _❑MONITORING ❑HOLLOW STEM AIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA; <br /> _❑EXTRACTION:Vapor!Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF_CASING: [3 STEEL C1 PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED; ❑Yes,E]No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —ID INJECTION(Le.Air Sparge,Ozone!❑HAND AUGER GROUT SPECIFICATIONS <br /> _Q OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE.ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> _Z__#OF WELL(S)TO BE DESTROYED -BOPE DIAMETER OF T�INCHES TO DEPTH OFFT <br /> WELL IDs: A/,Y k. COVERRESSURE GROUT TO DEPTH OF 3 FT BELOW SURFACE , <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: ❑AUGERS..E] HOSE JEPIPE ®.MUSHROOM CAP AT(>3 FT)—.3 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 thWwbrk will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applic tle California Laws. <br /> Signed TitlelCompany �t,PrintName; 'Jib <br /> � j � tDEPARTMENT'USE ONLY <br /> SITE MAP IN UNIT IV FILE IT ADDRESS D IJI aal__ <br /> WORK PLAN DATED 2_41 t70iiL <br /> Y. <br /> APPLICATION ACCEPTED BY � .. DATE ISSUED Z AREA <br /> i` GROUT INSPECTION BY FINAL INSPECTION BY __ DATE �3 1 <br /> DESTRUCTION INSPECTION BY __ DATE ��/��Z& <br /> COMMS NTSICONDITIONS: <br /> r <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED. CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST �P;R# <br /> �SbZ $125 x _ zSv� 2 17i SR#D�7�v3/ 2 <br /> SD 37 .. [/ ( ? L� KU?F <br /> 6D1 <br /> PR# <br /> 2900 N,A <br /> !'._F7 SAIr- 1A/A1%/CR' - r..1;7 I FTTFR f11=Al 1THOP17AT1CIN Tr)cur-hi PPPKAIT - FN(`.Rr)AC:HRAFNT nr)C: <br />