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I <br /> I <br /> oa.`''t. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> F-661 SITE MITIGATION <br /> 600 East Main Sire a,Sfackton, CA 95202-3029 UNIT IV <br /> % Telephone: (209)-468-3454 Fax.(2.89) 468-3433 Web:wuvw.sigov.orglehd <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOP.CONT N <br /> AtJll AEr INVESTIGATIONS AND REMEDIATION <br /> 3 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRO M SATE ISSUED <br /> Application is heret)y matio to son Joaquin County for a permit to constme,and/or install the work described. This applicoficn is mado In mmplianca with San <br /> Joaquin County Development Tittle,Chapter 9-1115-3.ano the Stancards of She san Joaquin County Fnvironmantal Health Department. <br /> Site Loeatipn W <br /> f u c.:, f CIGACross Street _ City._ APIV�Z <br /> Property r . <br /> Owner 'fes ��t-�/'7 Address C& L Ac"i.S/ City Sk, Zip one <br /> �o Ph __ <br /> C-57 Contraster �r. (1" dcl.s <br /> r <br /> f���AAA L Cily.Ifi11✓r's r tic �7Fhone !� <br /> ConsultantlSub Cntr 1143' rn - ryddrass '� / .�- S ��_� 3 <br /> i z �jrnf� �._ Cityi..r• t� tic G Phone i Gc. <br /> Bi}labia Party liN l �n crlr �� J Address k S' ly G4 �,!Y i1P phone <br /> GIS Caordinatas:X�G�z v=(�L�., f 7 Z <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING tL-PT,GECPROSE.HYDROPUNCH,HAND-ALSGFR.OTHER) <br /> ©SOIL BORING JDs <br /> ❑WELL IDs <br /> El OTHER IDTYPs <br /> E&#OF WELLM9—RlN—Q INSTALLATIOtt!TYPE CONSTRUCTION SPECIFICATIONS <br /> —0 MONITORING 0 HOLLOW STE.vm DIri.DFRCRFHC;.E ._•. ❑MUL 71PLE C4SINGS Q MUL7I.LEV;1"WELL CASIN,CIA- <br /> -0 EXTRACTION:Vapor!Water 0 HAMAAER/Gt:1VcN CASdt+tz_THICX1:rSS �E OF CASING: ❑STEE;. ❑FJC lv ofHE.R <br /> _❑SOIL VAPOR PROBE ©MUD ROTARY DEPTH V=GROUT S=AL—T-REM!E TYPE TO BE USED: <br /> _�]SOIL!BORING ❑PUSH POINT fGP!CP SEAL 11 ❑AUGERS ❑HOSE [�PIPE <br /> GRCE:T. AL P,tv1PEa:❑Yrs ©tae(3r,.xl 'UA4 FREE FALL DEPTH IS se F') <br /> T, ihIJECTION�e AlrSnnrrle�a•�❑HANJ)AUGER GRaJT SPECIFICATIONS <br /> _t7 OTHER: (]OTHER:, APPROX,BORING DEP?H ❑BOLT ECD 7RAFFIC BOX OR ❑S7OVE PIPE <br /> COMMENTS: CONDUCTOR CASING[]No❑Yrs:Cas7.:ng ryoa C;,-nn Depth: St:ring OtEi: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE=ACCESS AGREEMENTS OR,ENCROAC14MENT PERMITS <br /> D1=STR C ON WQRK TO BE PERFQRMED: ESTRCfCTIQtJ M,ETHO CHEcx AL THAT AaFLY <br /> #OF WELL{5}TD 9E DFSTRDY£13 pl/rC�_F;Cr;E rIIAMF7FR OF INCHES TO DEPTH DF C/'�/J"/1�n <br /> FY <br /> WELL IDs: LJ PRE•SSUPE GROW-TO DEPTH OF <br /> GROt1T SPECIFiCATtONS u.J'' u y - - ❑EXPLOSIVES cRosf To 7 B�'LC�'f SURFACE <br /> TREMIE TYPE TO BE USED:®AUGERS ❑NOTE ®YiPE CI E:XPLMUSHROOMVEGA?,. ]3 FT) <br /> =T RFLOW SLWAr.E <br /> COMMENTS t . c+ln;v_ (�r y,.."A {- �rrT rIp- W SURFACE <br /> 5 WORKING DAYS NOTICE REQUIRED tAFTER PERMIT ISSUANCE} 0-k!INSPECTION APPOINTMENTS <br /> hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances. Rules and <br /> Regulations,and ail appneable CaliFornfa taws. <br /> • <br /> Signed ThInIcortpany <br /> Print Name <br /> _—_Oare <br /> DEPART LIENT USE Of�LY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED -- <br /> AP?'tICATfON ACCEPTED BY <br /> GROUT INSPECTION BY BATE ISSUED ARCA <br /> i•I?d.4L INiPECTIfl�9Y <br /> DESTRUCTION INSPECTION BY DATE <br /> _.._. - <br /> COMMEHTSICONDiTION S: DATE -- <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE rNFO AMT Rrlvimm.) CH ECK f: ^"T- SERVICE PO# <br /> RECV'p BY I hgTE REQUEST PR# INVOICE <br /> 3 122 x - <br /> I SR# <br /> RO# <br /> 1 PR# <br /> G-57 WC <br /> ExD 2s-0 _._WAIVER <br /> 7 07128110 C•57 LETTER OF AUTHOF IZATION T?=N'._P.ER_M.I.T_ 2E3oVCC <br /> ;bACIF. <br /> �i'UCC <br /> L"JELL PER3,1rT APP <br />