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RP7CEIVEDS301AiGSl11W83d <br /> _ <br /> �iI-NSH IVIN3NNOWAN3 <br /> Y �4. �13 DRcRIGINA_ <br /> SAN JOaQ61N COUNTY <br /> ` A4�TH ENVIR NTA �ALTH UEFA NT �� <br /> H1 <br /> - - Telephone:(209)CES <br /> 3AISMM <br /> 468-3484 Fex: vI► <br /> (209} 468-3433 Web: ww.siyoV.orQlehd <br /> WELL & BORING.PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINAIdi INVESTIGATIONS AND REMEt11ATION <br /> NON-REEjjNDA8L_1=PFRMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby mads to Sen Joaquin Couny for a permit to construct andfor Install the work dascn'bad. This 3ppr=ton is mada.in mrp;iarice with San <br /> Joaquin Ccuniy Development Tit e,Chapter 9.1115.3,and the 8landards Y the San Joaquin County Enrvir`omental Health DenartmenL <br /> Site Location�roperty _� 70 61:._'4ky /14 CIOSS Street !�i'LEA` ./ftp / CRY Tfce 7i='` zip-_y�� O APN /2 2 <br /> Owner /!�46 r /�'f4Cr�P77 � Address I li l_lXrll�str�.7= city Cf II' 7ap�phone d 't} <br /> C-57 Ccrttracter /y.Address �1 City)?2,r`l�,f a Lia_ /�27 Ptxme 2,67 3 7 <br /> Cansuttanti5utl CntrI rr Address _l�Sr{ _�E rnr _ Cily 11i�s-. .tc� Lk./ a Phzae,%lb rQ'-00t <br /> 9)IT:hl6 Party I GJ#�rn �Fi . Address t e?_:i� L ctty,-ars✓.zlp �'? -honed 6.Gef 3.7t'•' <br /> GIS Cnordinatas:X_ 7 2,2-. <br /> CONSTRUCTION WORK TO BE PERFORMED. <br /> NEW WELLMORING(CPT,GEUPROBE•HYDROPUNCii,HArd)-AUGER•OTHER) <br /> I]SOIL BORING!Ds <br /> ❑WELL IDs <br /> ❑OTHER tOs <br /> TYPE 1!<*QF MIL•11BORING INSTALLATION TYPE. COUSTRUCTION SPECIFICAT[ONS <br /> MONITORING ❑Mtn Low STEIN RIA.0;:BOREHOLE . .., �13 MULTIPLE CASINGS Q 1AUL7.1-LEVEL VvE t CASING CIA: <br /> _L3 C•XTf1ACTtON:Vaparf Water ❑HARWERIORN N CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> 3 SOL VAPOR PROBE ❑r4UD ROTARY DEPTH OF GROUT SEAL TRENIIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> SOIL 0DRING E3 PUSH POINT(GP!CPT) GROUT SEAL Pum Pap.EI YM (]-r•1a("IMUM FREE.FALL DEPTtt is so"FT) <br /> INJECTION Ae Al S:p m—QZM Q HAND AUGER GROUT SPECIFICATIONS <br /> —00TH=R: ❑OTHER: APPROX.BORING DEPTH _ (].BOLTED TRArFIC BOX OR .O STOvE'plF[ <br /> CONI]UG ACR CA804G E3.4.❑Yes:Ca.tjng D*0: Cn3lnq 0jj: 8O&M dla: <br /> COMMENTS. <br /> NOTE: OFFSITE WELLS& BORN S REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DF-STRUC110H WORKrTO 99�� RFO M ' " y 5 ON T CH CK THAT PP Y ` <br /> BE ,.JcSTROYEM - • ��� •�''u'4l MOVER-BORE DIAMETER.OF INCHES TO DEPTH OF Glyn FT <br /> t�i�ON211-0'r <br /> f,a4 crrG Iv1 w� w7 PRESSt1RE GROtI fTt)a arH as FT eELOw s[mFAceQ EXPLOSIVES Mom TO FT RFLOW SURFACE <br /> TREMIE TYPE TO 6E USED: AUGERS C1 HOSE ®PIPE Q MUSHROOM CAP AT(y3 FT) FT eRovw suPFAce <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 b&done in accordance with San Joaquin County Ordinances.Rules and <br /> Ragulalions,and att II a 'forma laws,. <br /> Signed Tilte/Camparry <br /> Prin!blame _ Date. 5/ 7g /I3 '�^R <br /> 'DEP ENT USE ONLY . <br /> SITE MAP IN UNIT:V FILE-SITE ADDRESS <br /> WORK PLAN DATES} . <br /> APPUCAMN ACCEPTED BY DATE <br /> E ,y <br /> CRO <br /> lNSPZ C7I011 BY FINAL IN3PE&ON 8Y 20 E <br /> DEEMUCTION INSPECTION 6Y [TATE `1 <br /> C.OMMENTSICONDITTONS: <br /> ACCOUNTING ONLY: AID 9- FAC 9 <br /> Pc'CODES FEE INFO AMT REMITTED CHECKA RECV•D BY DATE, SERVICE RD kIhiYO10E <br /> REQUEST PR# <br /> SR# <br /> 3– ~4o RO# O <br /> 35 <br /> PR# <br /> 291HI <br /> C=57 WCWA1Ve}i _ G 57 LETTER OF AUTHORIZATION TO SIGN PE12M17 ENCROACHNISNT DOCS <br /> GHp29•pi e71281S0 VVELLPEPWRT'.APP <br />