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RECEIVED <br /> SAN JOAQUIN COUNTY MAY 0 21011 <br /> LOP <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION <br /> WU <br /> 600 East Main Street,Stockton,CA 95202-3029 EMRONMENTALMOFMT/SERVICEs— <br /> Tis«Helephone:(209) 468-3454 Fax:(209)468-3433 Web.,www.si-q e <br /> WELL & BORING PERMIT APPLICATION. <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT UPIRES I YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andfor halall the work described. This application Is made In compliance%01 San <br /> Joaquin County Development Tide,Chapter 9-1115.3,and the Standards of the ran Joaquin County Environmental Health Department. <br /> Site Locathx"457a�� crosssbeet r <br /> APH <br /> k�Xlv-�" Address <br /> city Phone— <br /> city hone'k.Ar-&Z <br /> C37 Contractor P <br /> I- ConsuhanUSub CrNGo c, s�a*641 Uc—Phone ZZ-W3-43 <br /> BillablDparty CA 7jp -7SWA, <br /> Address <br /> GIS Coordinates:X <br /> CONSTIRUCTION WORK TO BE PERFORMED-, <br /> NEW <br /> El SOIL BORING IDs <br /> OWELLIDs <br /> 0 OTHER IDs <br /> 3Y :&#0FINELLIDORINGINSTALLATION TYPE CONSTRUCTtON SPECIFICATIONS <br /> ( —j:1 MONITORING E3 HOLLOW STEM OtA.OF BOREHOLE_t3 MULTIPLE GASUIG$13 UULTIAEVEL WELL CAWNG DA— <br /> —j3yxmcnow:v.Pwjwt& b NAMmERA)Rwem CASINGTHICIDIESS TYPE OF CASING.b STEEL ri Pvc o OTHER— <br /> n SOIL VAPOR PROBE [3 HUD ROTARY DEPTH OPGROB'I'SEAL—TREMETYPETOREUSIM.GAUGERS CIHDSE,t3PIPE <br /> _[I Son.BORING 13 Pusm POINT(opt cpT) GROUTSEALPLIMPSIX.ElYes EjNo(M=N1UMfREEFALLDEP7N1S30Fr) <br /> _E31NJECTIONILOJsraw, 0 HANDAUGER�GROLITSPECIFICATIONS <br /> _j3orHER,_[3onrNBR.APPROXSOR94GDEPTH—0SOLTEOTRAFFIC BOX OR L3 STOVE PIPE <br /> j. <br /> COMMENTS, CONDUCTOR CASING 13 No 0 Yer:CaIog DW— h Cadre Dept —00ft Dir— <br /> NOTE OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DES 1RUCTION WORK TO BE PEffQRMED: ONMETHtw-(CHECK <br /> DLA.METEROFfna NCH ES TO DEPTH w—It�9-0,r <br /> _-W-0OFWEkJ.(8)700E DEW—ROVED ER-BORE gtTRATAPPLY) <br /> WELL We: PRESSURE GROUT TOOMPIrM OF .FTeetnwsuRPacE <br /> GROUT 'FCI TIO <br /> [3EXpLOSjVESH,,,,_yO_____fTSELOWSBRFACE <br /> TRFMIE SURFACE <br /> gTOSSUSM.AAU ER3 HOSE IPE rr <br /> ENTSJ/�-&� g,, <br /> SPECT <br /> Cow 11, "'GEM=V aL7--C-;UamaPS <br /> 45 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> i hareby cerw That I have prepared thic applicatten and Unat the work vdR be dome In accordance with San Joaquin CvunV Ordi"nucm FinIns and <br /> Reputations, lawns. <br /> Signed Titalcompany 1-1 <br /> PdrdName _5eely- zzt 's Date <br /> DEPARTMENT USE ONLY <br /> V1,0,,' SLUR ) <br /> E- <br /> SITE MAP IN UNIT IV FILSITE ADDRE <br /> N DATED <br /> WORK PLA <br /> ki APPLICATIONIAOCEPTEI)Sir'/-Jj�� DATEWLIOD 1. AREA <br /> si <br /> GROU.rINSPECTIONBYFINAL INSPECTION.By DATEDESTRUCTION INSPECTION DY DATE <br /> OMMENITUCONDITIONS. <br /> ACCOUNTING ONLY: AID# FAC <br /> SERVICE fzo# INVOICE <br /> GOES RE UrST PRO <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECvO BY DATE <br /> SR9&06 Z Y3(0 <br /> ROO <br /> 1,01 44� <br /> (2900 <br /> T ENCROACHMENT DOC.— <br /> 0.51 WC_W)IJVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMI WELLPERMITAPP <br />