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ct+'I•+`" SAN JOAQUIN COUNTY <br /> z ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stockton,CA 95202-3029 SITE MITIGATION <br /> Telephone:(209) 468.3454 Fax:(209)468.3433 Web:www.sioov.or <br /> "ii glehd UNIT IV <br /> ��o$y <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to Conslruct and/or install the work described. This application Is made in compliance with San <br /> Joaquin County Dawopmenl title.Crispier X1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location CNIAl MOW Cross Street NwN 580 city. T(A/� _Zip955141 APN 75t- 12-p4 <br /> Property a� <br /> owner F;TCWN.$hffiW�1 Address tzo a%. 411 city L4tCA51 Ae, Zip93040 Phone6A"1-66-/,. 9`1 <br /> C-57Conuaclor til DY1k`!n Address 220 a. eo--A N. City WDOOMO^A Lit 60213 Phone S liD !f.e•�4'7-aY <br /> ConsultanlfSub CntrCJA00 Address-1.110 PafQt L4v&-S1C•IODCity 00-kl" Lic n1`1CtaE e510.1.3/"8500 <br /> Billable Party Address 9"1-10%CAbt..La.va_82c.lob City Deik4Rv.R Zip"14-tv;24_Phone 5lD'6s! ( S=JOD <br /> GIS Coordinates:% Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW W ELLIBORING(CPT,GEOPROSE,HYOROPUNCH,RANO-AUGER,OTHER) <br /> SOIL BORING IDs <br /> WELLIOs IsM — <br /> I ❑OTHERIDs <br /> TYPE s#OF WELLIBORING INSTALLATION TYPE CQNSTRUCTION aPECIFICATIONS <br /> Z�MONITORING OI HOLLOW STEM DIA.OFBOREHOLE v <br /> ❑MULTIPLE CASINGS❑MULTI•LEVEL WELL CASING OW: <br /> EXTRACTION:Vapor Water D HAMMER/DRIVEN CASING THICKNESS Sun.40 TYPE OF CASING: ❑STEEL 14 PVC D OTHER <br /> _Cl SOIL VAPOR PROBE C MUD ROTARY DEPTH OF GROUT SEAL TREMSE TYPE TO BE USED: D AUGERS D HOSE D PIPE seelele <br /> _D SOIL BORING D PUSH POINT(OPI GPT) GROUT SEAL PUMPED;pl Yes D No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —C INJECTION e Ar eee,oe ocanel D HAND AUGER GROUT SPECIFICATIONS NCaAr Casrs6Pk <br /> _O OTHER: COTHER: APPROX.BORING DEPTH NIA -50r 19 BOLTED TRAFFIC BOX OR [3 STOVEPIPE <br /> CONDUCTOR CASING ENO DYes:Csslna Dia:�Culn#OSPIR_ Sodlp Dia:. ♦ r <br /> COMMENTS: �rq <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS WIo <br /> DESTRUCTION WORK TO BE PERFORMED: nEQTRVGnON METHOD•ICHEcIuI LTHAT APPLYf <br /> _#OFWCLUS)TO BE DesrROYED ❑OVER-BORE DIAMETER OF—INCHES TO DEPTH OF FT <br /> WELL IDS: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FRoM To FT naOW SURFACE <br /> TREMIE TYPE TO BE USED:O AUGERS C3 HOSE ❑PIPE [3 MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby evilly that I have prepared this application and that the walk will be done In accordance with San Joaquin County Ordinances,Rules and <br /> RoaulaUgns,and all applicable California Laws. _ ,_) 1 {� r <br /> Signed rte. L_ L U -` TIUeiCompany �It(r' pfesl(.11il'-L I�Lr.+S� L r-), :I IJ4, f. <br /> Print Namne — —Y\ _m {�I/1,=t.[ I Date •] i l <br /> J DEP RTME T U Y <br /> SITE LMP IN UNIT N FILE S A RFSS S 2— <br /> WORK <br /> WORK PLAN DATED U <br /> APPLICATION ACCEPTE DATE ISSUED // ARFA <br /> GROUT INSPECTION BY IJ�1.A.1w fu .�, FINAL INSPECTION BY IAk:_k� OATE 2a I <br /> DESTRUCTION INSPECTION BY DATE <br /> COMME NTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEEINFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> d901 125. eYJ CC 3 zyP l-► c, ,b / SR (0-7 ( <br /> 0 37S ��� " r <br /> A9PRO <br /> ]500 <br /> ;"7.0 7S 3�� � PRO <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT OCC <br /> rd °COQ copy <br /> 1 FILE <br />