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uln. SAN JOAQUIN COUNTY <br /> � .. <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> Telephone: (209)4683147 Fax:(209)4683433 Web:www siaov.Ordeh <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 Sen Joaquin County for a permit to construct andlor install the work described. This applications made In ebmpfance With San <br /> Joaquin County Development Tide.Cha ter&1115.3,and the Standards of the San Joaquin County Environmental Health Department <br /> Site Loraton ZtJ�lel l.J, t-�4mK;r Cross Street �On I}f�rCn�Zr City/State 5---�/Zip °Isoo9 APNO�S 'ylO-D <br /> PmpeRyPe� S'.��1_ l /k -�I Address 1fi]O 1C01e5Si`a.-,.X Dr Gh'/State s°1C fkA'�"Zip r9 u�(l� Phone 'I yEl'�g3 <br /> C"11°r `�"� n Cw4 qzs-P49i�17� <br /> C_67 Conhactor `� Fy Address 1U411 1�2 d'n`'� Cdy/State Iuca:jGb Uc '�s`R� Phone <br /> ConwRartUSub Crtr Address City/5fete UC Phare <br /> Billable Parry Address City/State Zip Phone <br /> GISCoordinatevX Y <br /> CON TRUCTION WORK TO BEP ORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> 0 OTHERIDs <br /> TYPE A i OF WEUMORING INSTALLATION TYPE CONSTR!&'nON SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DU.OF BOREHOLE _ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> _'l EXTRACTION:Vapor(WSW *fig-f1AMMER1DRNEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> —0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> _EPSOIL BORING 5kPUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yea 0 No(MAXIMUM FREE FALL DEPTH IS 3D FT) <br /> _❑INJECTION L4S A, 19 HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER'. 0 OTHER. APPROX BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> p ( FONDUPTO�R CASING 0 No 0 Yee.Cdna Dia: Cama Depth: 5wng D6:_ <br /> �t <br /> COMMENTS: Ltlmiof FV Ion "'3S D �C� I`rd V'+� SQ'MO //�L C <br /> NOTE: OFFSIITZE WELLS S BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD•(CHECK ALL THAT APPLn <br /> Z OF WELL(a)TO BE DEaTRoY D ❑OVER-BORE DIAMETER OF INCHESTO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FTBELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERSEI HOSE C1 PIPE ❑MUSHROOM CAP ATL3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby ceptfy that 1 tave prepared this application and drat the work will be done in aeeordaRy with San Johsqu Ln County Ordinances,Rules and <br /> Regul ,and all licable Califomm Laws. <br /> Sighed �"(r— Trtla/Company <br /> Pnnt Name a'IWaFA� Date ? / <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT rV FILE-SITE ADDRESS 1'5'� 9 (A ) k4m(,?e R 09/V6' <br /> WORK PLAN DATED 4 B U 2 20/3 <br /> APPLICATION ACCEPTED BY J-yo 9^Ur+'I DATE AREA 16 <br /> GROUT INSPECTION BY FINAL INSPECTION BY kctDATE 3 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CO NDITIONS: <br /> ACCOUNTING ONLY: AID i FAC S <br /> PE CODES FEE INFO AMT REMITTED CHECK/ RECV'D BY DATE SERVICS RO: <br /> / INVOICE <br /> REQUEST PR/ <br /> $125 s E T_ 103 7 65 GI'v6.�T64- 3-5-f 5 SR* 7G <br /> -375 Owl <br /> FIRS <br /> C-57 h' WC v WAIVER L'VA G57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC VA <br /> EHD 2941 5)M12 WELL PERMIT APP <br />