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- ' QRECEIVE® <br /> SAN JOAQUIN COUNTY MAY O 2 70i oP <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 11it. EWRONMENMITIGATION <br /> SITE <br /> AL <br /> 600 East Main Street,Stockton,CA 95202-3029 �tlulr 0 <br /> �llRi <br /> onp s Telephone:(209)468-3454 Fax:(209)468-3433 Web:vrww.SiaoV.PrSTestl <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 Construct Red/Or install the Work desabed. This applicat'on Is made In Compliance With San <br /> Joaquin County Development Title,Chapter 31115.3,and the Standards of the San Joaquin County Environmental Health Department . <br /> Site Location J3%,&�E(�,,. 5 CF`ross sheet r,,!- ifto„S/'-dv 5-A'/r4. zp_rl5lov APN 125-z10-3o <br /> I'Owner({A{irFtl-1G.µ .. L.r.. Address d_.,??ol�aKiFl� .._j. City .S�a c�cl'�.� ZIP, c7 52c, Phone <br /> C.b7Contractor i [f;- Address 4Sb /faStN t< Cay /L7,c,F�,.�x14ic Gs'7Y85/GSPhOne Wf3/3-5'8'nn <br /> Consuhani/SubC-"4!<-; c. rltddress�jYYt.t:.en aQe biy$+.IJSeGity Lic Phmrezo7-433-ZJ <br /> Billable partyc""� , <br /> s 77YY4/G.,,sfiQ.,!H' S•:k e <br /> {� <br /> Ad�es71p 4TV7L Phone 7g-7-933-416'7 <br /> GIS Coordinates.X JJ .nay3`, r— <br /> CONSTRUCTION WORK TO BE PERFORMED• <br /> ❑NEW WFJJJBORING(CPT,GEOPROBE,HYDROPUNCH•HAND-AUGER.OTHER) <br /> 0 SOIL BORING IDs j <br /> 0 WELL IDs <br /> [3 OTHER IDS <br /> TYPE 8#OF WELLBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _ <br /> _0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE _0 MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA <br /> _❑EXTRACTION:Vaporlwater0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> _(]SOL VAPOR PROBE <br /> [3 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Cl AUGERS 0 HOSE 0 PIPE I <br /> I _0 SOL BORING D PUSH POINT(GPI CPT) GROUT SEAL PUMPETk 0 Yes'D No(MAXIMUM FREE FALL DEPTH IS 30 Fr)' <br /> I <br /> _D INJECTION ae."SIsaa,O oat O�NAND AUGER GROUT SPECIFICATIONS <br /> _D OTHER: 0 OTHER APPROX BOPJNG DEPTH- .0 BOLTED TRAFFIC HOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING 0 No El YM Casing Dia:_Casing Depth_Sarno Dia_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED, T U N gq ALL THAT APPAM <br /> DC#0 WELL(S)TO BE DESrRO O 4- R-BORE DIAMETER or$ A HcHES TO DEPTH OFYO'Jro FT <br /> GROUT SPECT A `''-6 "- - []PRESSURE GROUT TO OEM OF OF rT BELow suWAcE <br /> WELL IDSTREMIE TYPE TO BE USED-JRAUGERS OHOSE U IPE �EXPLOSNES FRON TO rr eELow SURFACE <br /> COMMENTS`1 r,.rQ ^x 4if'a� Y t f a Y"Dr FI MU HR7M C Ab . BEL sus ACE <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS e <br /> 1 hereby cerft that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordlnancos,Rulas and fl{ <br /> Regulations,and all applicable California laws, <br /> SI9 r TiIMJCornparry �co�G is - _,c�R<-��a F/R.<So4o - <br /> PdrdNamB5�.�/f r�S Date Y-2/—/! <br /> ryry DEPARTMENT USE ONLY !!� //� <br /> SITE MAP IN UNIT N FILE SITE e ADDRESS �') 71A • f S'CtrL iFO�. L D� S,-62'/ <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE ISSUED f AREA <br /> GROUT INSPECTION BY FINAL INNSSppppEECTI BY DATE ' <br /> DESTRUCTION INSPECTION BY- - DATE.412--K �.O L I <br /> COMMENTSfCONDMONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> coi S 122X g J� &-D?8 a9ll SRN 006�z1 v3 <br /> ON <br /> �7X �- �N 3500 1 L, I Z <br /> pR# <br /> 0 <br /> - G57 WC WANER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHDYP-0t 07wlo WELLPERA'tlTAPP <br />