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s <br /> ORIGINAL <br /> �aea� .A SAN .JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> t0 ` SITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> • ..-.. : .:;�. To ie ph one:(209) 468-3147 Fax:(209) 468-3433 Web:www.sia ov.ora <br /> /en <br /> Ctpp N <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NONE-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicnilon 1.hereby hied-to San Joaquin Co my for a perm ix to con9tru ct end/or init.11 th.work tles<ribe tl. Tht.epplic atlon Is mode In eom plln nce wish Snn <br /> J..gain County DovolopmehtT,l ,Chapter 91115.3.and the Standards Ifcha San J..guln County En i,.rm.ntel Health D.p.rtmbnt. <br /> Sit.L...tl.. 93v 5.414-- Crd..Stf.-x City/State :P �,,��,/Y.�w ZIP G ,[�'S <br /> APN '.�5©C1 <br /> Property 4 veI- ee <br /> l <br /> ow..rf,Ts�r� Lut.6Pr/di+�s A..­.a /!9/$/c.Gry �.v� Eirole clty/ci a. 71p 4yS5� Ph .51S yy3.5'? <br /> C-57 C..tr..t.f V if IAJ A.tr...3g'� A!/o''f Cf .qG�___ City/Stntd 4rJJJLi LI��iZ�d�Phdn. f716"?-- 7� <br /> _T <br /> C....1t 11S„/b//LCntr�O 114'±d _ A.......2!?1y7 11eXe41&"- <br /> Blll.ble Party 4 e& Affil- ` Addras. 5SHM Clty/Stnx Zlp Phnn. <br /> GIS C.drdlnata.:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT.GEOPROBE,HYDROPUNCA,HAND-AUGER,OTHER) <br /> ❑SOIL BORING ID. <br /> ❑WELL ID. <br /> I ❑OTHER ID. <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:V.por/W.t.r ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER . <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> —❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Ye. ❑Ne(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(....a.S..e..O.e.,.)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑Nn[IY..:C,.1.,D,.: C.. D­­: Bonn,D..: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DE TRAY D j2rOVER-BORE DIAMETER OF�.4 Z INCHES TO DEPTH OF 'S 5 FT <br /> WELL ID.: s'-fe WDY !� 'sI G &Y//3 PRESSURE GROUT TO DEPTH OF SS' FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TCBE USED AUGERS ❑HOSE PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS &LTQ/( � - G/a.4 /9 Ag-I 'gE� "//3 <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby o.rtlfy that I have preper.d th.e epplleetlon end thntthe work will be diol. In .teord.nca with Sen Joaquin County Ordlnanc.e, Rules and <br /> R.aulatlonpphc <br /> Il ebl.Callfornie <br /> S"... nd e h Tltl./Company GC2w2c6afr— 13, /l e� 5'Tmr•4 X7"11 <br /> 'IfPrint Name _ Syr_ L G� 4 or Data Zc /3 <br /> DEPARTMENT USE ONLY C /--•� <br /> SITE MAP IN UNIT IV A IT ADDRESS JU _ /� &1-0- U 1)? <br /> WORK PLAN DATED l <br /> APPLICATION ACCEPTED BY DATE <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE �' <br /> COMM E NTS/CON DI TI ONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 0?i $125. ha, lc $ 3 SR0049 <br /> 3 r 3?S" Roo ?.0�3 <br /> 0o <br /> C-57 WC WAIVER C•57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29.01 5109112 WELL.PERMIT APP <br /> _ I <br /> ' f <br />