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w RECEIVED <br /> SAN JOAQUIN COUNTY N.� MAY 14 '! 'J t <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> a. ITMITIGATION <br /> + ��L'�� :�• 600 East Main Street, Stockton , CA 95202-30�VIRONMENTAL H��.IE <br /> ' p Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www,W*Wf6raH!'.F4 UNIT IV <br /> �%FORµ• <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS ANDRE f�Ep4l]I �t� I AA L <br /> NON-REFUNDABLE PEWIT EXPIRES 1 YEAR FROM DATE ISSUED U CR\ ` <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made In compliance with San <br /> Joaquin County Development Title, Chapter <br /> ,A9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Locatlon25a5000NTP( CiSiy`crossstreetPLY „dafHa`�tD CitySrUGKT00 Zipg520 APN <br /> Property <br /> owner Pav10 A MLgKCMfK Zi 9yS9to Phone Np <br /> 0%100tAddress LL6Y t2 581 Yalvteu� Vpgra city p <br /> C•57 Contractor 6RE64 OIZ((I.I NCS Address 960 kyt✓6 QWV cityMACTIN6;t Lic W1b5 Phone Tz5- 3 /3-5800 <br /> ConsultantlSub Cntr CRA Address 1096q'T,Yy}Di•t6tg8Qp�IV,Ef''r1c ,Q,yNW tl.gLic Phone 9/b -589— 010 U <br /> Billable Party DRQ Address TR►ME G.lW D VECity t(pV0K,(0Koo.Vip 956 Phone <br /> GIS Coordinates: X Y ��/ '/ <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) <br /> ❑ SOIL BORING IDs <br /> ❑ WELL IDs <br /> ❑ OTHER IDs <br /> TYPE & # OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE b� ❑ MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> ❑ EXTRACTION: Vapor/ Water D HAMMER/DRIVEN CASING THICKNESS .CL!} No TYPE OF CASING: D STEEL D PVC D OTHER <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL Jr I TREMIE TYPE TO BE USED: D AUGERS D HOSE D PIPE <br /> D SOIL BORING D PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes D No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> 0INJECTION go .ArSoaroe. Omne1 ❑ HAND AUGER GROUT SPECIFICATIONS FORTLArroL6HC�r'IT <br /> _D OTHER: YCOTHER: Aliflef fFE APPROX. BORING DEPTH 2or � BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br /> W OKKTOP E P� y1FD : CONDUCTOR CASING No D Yes: Casing Dia: -wils%eines°gyp pth: Boring Dia:_ <br /> OOp�p�µ7.S- ARE PA11C W6LLMW' 1� `NEIL CASINEI C E N NAY W, pµ1 O . REHMIEII rj-qrr FILTERPNCK� NpteE <br /> ¢ EPgIRS SWELLS LL 9T cUI C�CCESS 7£'R 3� <br /> NOTE: OFFSIDE WELLS & 8I� INGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> # OF WELL(S) TO BE DESTROYED ❑ OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑ PRESSURE GROUTTO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES mom TD Fr BELOW SURFACE <br /> TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT (>3 FT) Fr BELOW SURFACE <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 be done In accordance with San Joaquin County Ordinances, Rules and <br /> Regulations, and ally��ppiicable Cali�Xpmia Laws. <br /> Signed J'C""-r� ./ - Title/Company PRQ� 41- AAll I CIZA <br /> Print Name LA-Ell EI LVA Date MAY I , ZOI L <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS <br /> WORK PLAN DATED - --- <br /> APPLICATION ACCEP DBY D S ��� /a AREA <br /> ,c,,� <br /> GROUT INSPECTION BY FINAL INSPECTIO �7T11i/�3 DATE4 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: �J�/ Ohi-� �rz ' m <br /> ACCOUNTING ONLY: AID # FAC # <br /> PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SR E QUERVICEE ST RPRO ## INVOICE <br /> d9i3 $ 125 / i�S. o0 3ioa6 SR# <br /> RO # <br /> (3500) <br /> PR # <br /> (2900) <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> i <br />