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p4 y SAN JOAQUIN COUNTY <br /> ARONMENTAL HEALTH DEPARTM NTE CO LOP <br /> N' 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> �;-...... ' " UNIT IV Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.org/eh U !�'� <br /> WELL & BORING PERMIT APPLICATION 2.o ��, <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEf�II�jF E^u <br /> M <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 comtan San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health DepartmenNO V 92 It�rh <br /> Site Location /969 G/. /'N anter t4J JGross Street t'Ccg.o /J vc City {u fr tsN Zip-�+j--SZcHr.��r,,APN <br /> Property ` CIY V IRONMENTAL HEALTj-I <br /> Owner G/c.rn n5r j04tnrjilrrc Address Sdu SS Lt3)- Frrn.x-.l„Sfi if So City L /(�s� TX' Zip7SZY°/ PERtAICP+AQ��'-S rwrSy <br /> C57 Contractor Win✓- Cm-rJ+xl//sr t./„r Address >'E+l Tr...„ Pcirnr fir. _ City Apros l.9 Lich Phone 03(• 64.314 <br /> ConsultanUSub Cntr_ 9 Address City- Lic q *0 Phone_ _ <br /> Billable Party Address City Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IOs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> NITORI G ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: , <br /> _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER \ <br /> ❑SOIL VAPOR PROBE ❑,MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _TI <br /> SOIL BORING PUSH POINT PI PT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) QV <br /> _❑INJECTION ti.e Ar Soarae.ozone/ HAND AUGER GROUT SPECIFICATIONS �R/w�-�( <br /> _❑OTHER: []OTHER APPROX.BORING DEPTH S/ ❑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 /> _#OF WELL(S)TO BE DESTROYED [IOVER-BOREDIAMETER 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 ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 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 all/a II�y)le Ifornia laws. EAU <br /> Signed /.rhq/ /—`YTNe/Company P1'C-(, l�A U �✓L/Yy/."t S� d L' . � s��t <br /> Print Name /LL. Date I (J/ 2b R6 <br /> Q DEPARTMENT USE ONLY, JA 6 d t <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DAT 1 LED •'Zj�0 AREA �6 <br /> GROUT INSPECTION BY FINAL INSPECTION BY --,� z ' —DATE <br /> DESTRUCTION INSPECTION BY DATE_ <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV•D BY DATE SERVICE RO# INVOICE <br /> REQUEST I PR# <br /> ZEDS $122, l 12,7- ft Z2-110 SR# Q01513 <br /> 2-903 <br /> 8005 2_XQ FAL COp z00)50J <br />