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a 4 • � Ll <br /> U I f- y <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> IT� <br /> \\ 600 East Main S(reet,Stockton, CA 95202-3029 SITE MITIGATION <br /> \Lrr. a Telephone:(209)468-3454 Fax.(209)468-3433 Web:wwwsloov.ora/ehd UNRIV <br /> WELL & BORING PERMIT APPLICATION <br /> QAC'°G <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION g��S <br /> NON-REFUNDABLE PERMIT EXPIRg 1 YEAR FROM DATE ISSUED <br /> ApplllaUcn Is hereby made to San Joaquin County for a permit to construct angor install the work descried. This application Is made In compliance with Sen <br /> Joaquin County DevelOPment Title,Chapler 9.1115.3,and the Standards of the San Joaquin County Envlmnmentat Health Department. <br /> Site Location 100015,1_! A: pp MCress Sheet N;dd�., Cnyv pi city 1=akAj1me 7JP_9_.33o APN 11-330"-10 <br /> Owner Address 370 1&t vie C&H L.L X PP <br /> C.57Contmctor - City ro be 95-330 Phone _ <br /> Prec;sLonja{nPl;r lddress 2305w;yLn� l�f, _ City SkGElan Ue_63&38� phone��G?)y65-871). <br /> Consultant/Sub CntT_ENIGEO I;& Address �IV. W IM QVa p Phone(109)¢35-Of°IO <br /> Billable Pa - Cu1'._6�C°Ya Uc <br /> rty P.K. D•5}r'GI- RE.l�' Address FO. Pvsv I1161 <br /> GIS Coordinates:X9•SI Y City 5{ Ck4O' ZIP-3-19,0_1 Phane(.'I°9)1j65--58B3 <br /> �{ZI.31$ _ <br /> COlISTRUCTKIN WORK TO 8E PERFORMED: <br /> HEW YYELLRtORING(CPT.GEOPROBE,HYDROPUNCH,HANPAUGE <br /> [I SOIL BORING IDs <br /> WELL IDs r,n; <br /> OTHER IDs <br /> TYPE 8 Y OF WELLIBORINO INSTALLATION TYPE CONSTRUCTION St,P�,ECIFlCATIONS <br /> _Q MONITORING AHOLLOWSTEM OIAOFBOREHOLE �rL RMULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA A <br /> _O EXTRACTION:Veped Water ❑HAMMEWRIVEN CASING THICKNESS SGH NO TYPE OF CASING: ❑STEFl KPVC <br /> _OBOE VAPOR PROBE [I OTHER <br /> El ROTARY DEPTH OF GROUT SEALm;n Nr THEMiE TYPETO BE USED:$AUGERS Q HOSE 13PIPE \ <br /> _I]SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑yea$(NO(MAXIMUM FREE FALL DEPTH IS 3C FT) [� <br /> _❑ IN INJECTION RA-&&M,DIM, OHAND AUGER GROW SPECIFICATIONS rtlyi�- Cwt. 4 <br /> /n <br /> _I OTHER: 21E1Q-C —S 0OTHER: APPROX.GORING DEPTH 2� �fQr <br /> / �+� ]iS,BOLTEO TRAFFIC BOX OR ❑STOVEPIPE <br /> COMMENTS• e a CONT�NGO10 rir:Cuing da: Casing Daplh: ea' Dq; <br /> r E <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AG EEMENT3 OR ENCROACHMEN PERMITS <br /> DtisTRUGTADN WORK TOB PERFORMED: pESTRUCTiONMERIOD:(CHECK ALL nur APw vt ;gyp <br /> _MOF WEl1(S)TO DE DESTROYED ❑OVER-BORE DIAMETER OF—INCHES TO DEPTH CF FT <br /> WELL T ❑PRESSURE GROUT TD DEPM OF <br /> GROUT SPEGFICATIONS ❑FJ(W.OSNES R FROM TO FTSELOW SURFACE <br /> TREMIE TYPE TO BE USED:pAUG ER9 HOSE PIPE CAP AT L>3 <br /> Fr BELOWSURFACE <br /> COMMENTS (_ E'n F'r BELOW SURFACE <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby earthy that 1 have prepared Ih)a application and that the work will be done M accordance with San Joaquin County Ordinances,Rules and <br /> Regulatbm,a It 2pea 6(C farnla laws. <br /> Signed Thl'ComPury SCnLer- �010�5� /�jtJ( j7 <br /> Print Nemo ac004 Date ��7�1f <br /> n z9�s <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS / - 7r �() <br /> WORK PIAN DATED L' <br /> APPLICATION ACCEPTED BY DATE ISSUED //-/� <br /> —AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSMONDITiONS: <br /> ACCOUNTING ONLY: AID Y FAC Y <br /> PE CODES FEE INFO AMT REMITTED CHECKS RBCV'D BY DATE SERVICE RI: <br /> REQUEST PRINVOICE <br /> 24 S122X /076. .7- 7-// IsR# <br /> ZRo 3k" % p( <br /> / 2� pr <br /> G57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br /> C-5 zs-Bt mrinnD F17CROACHMENT DOC <br /> WELL PERMIT APP <br /> FILE COPY <br /> S�- <br />