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n0."!•. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> ye SITE MITIGATION <br /> 1868 H.t.ettor, Avanue, Stockton, CA 95205-6232 UNIT IV <br /> -- �• Ta/epno.�:(209) 468-3147 Fax:(209) 468 3433 Web:wwn•..19ov.ora/a t, <br /> /F..:.. <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 /> App-.-1.nor...m...t.5.n J..'. C...ty rnr.p.,mltt...n.t,.t.wnd/.,tn.t.n 1h.w.,k d...rm... T..m <br /> J. .l C...n,,Dp ,.,,rb n Tal..,,�C—pt.r 9 1115.3..nd a,.S—d.rd. tet S.n J..q.n C..n.y F�vo-onm.n•..H..mn D.p.nm. <br /> $rc.L.c.tlon /�3 E'�.Gbr'��dCr.s.$[root��t�JM�/,�_ Gty/St.tc Zl�Zlp 9� APN�'_,,'7_4I�+q <br /> -- -- - .ld10C <br /> n Qts yy9•P—p. y Ftp Vol f P..OwnLTr✓r AdnYR­ <br /> C-57 J�'T✓/ <br /> C.-...... i/ _ A......3g� ,Ov6�f e� �d Ctty/st.,. srci LIQ ago Pb�.. �i'�19- 7 <br /> l C.n. tt.ndS bCnt.G�e/�hote A..r .2?lz� L—MeM G.y/5..t �> �LI. WgEv_P.."'. <br /> B-....P.rty ISCOe Ael-C. Ad.,... SQis-F tP Clty/Sr Zlv P..n. <br /> GIS C...d,n.t..:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: - <br /> ❑NEW WELUBORING(CPT.GEOPROBF.HYDROPUNCH.HAND-AUGER.OTHER) <br /> ❑SOIL BORING ID. <br /> 1 ❑WELL ID. <br /> I ❑OTHER ID. <br /> i TYPE&#OF WFLIJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ! _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> C _❑EXTRACTION:V.p.•f W.r.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 Cl PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Y.. ❑N.(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION I.-.Aa,s......o....l❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑W❑Y..:C..Intl D..: C..Ing D.—: B.r...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 TR}}Y D ,0'OVER-BORE DIAMETER OF oJA INCHES TO DEPTH OF S'S FT <br /> WELL ID.: ree At'O✓ DY! 1;"RESSURE GROUT TO DEPTH OF SS FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO)BBE USFD AUGERS ❑HOSE Q PIPE p ❑MUSHROOM CAP AT(;3 FT) FT BELOW SURFACE <br /> COMMENTS a ?'QA 0:4ft/e_ei ff02Ak 1 3 <br /> I <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I horn by c.rnry tont I h.—pr.poral t„t..p ptl..tl.n and cont tn.work-11 b.d...In.ee.rdw nc.wltn S.n J..q..n C.hney Ortl then....R......ntl <br /> R.p...tl.n... .1..ppu. 1.C.ur..n•.• .. <br /> t S",_' T.ndc.,hv..y Ar,C',SU�Q� /3a•r Y e� �Td!_'4 <br /> 7l7 +f <br /> Pont N..n. _� !/!_ ` Ger It OP D.t. <br /> DEPARTME T USE ONLY c n /-•� <br /> SITE MAP IN UNIT IV FI -`IT ADDRESS MC2 G GsG_r'��� T ty <br /> WORK PLAN DATED <br /> II <br /> APPLICATION ACCEPTED BY DATE ISSUED 2o1 T7AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE I <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# I <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE. RO# INVOICE <br /> f -7 b <br /> REQUEST PR# <br /> S 0L/ E 125. R J� <br /> 3� r 37�� R# ?,0,;,3 <br /> pin <br /> I <br /> C-57_ __ __ WC WAIVFR _ C-57 LETTER or AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29.01 bf09/12 WELL PERMIT APP <br /> I <br /> I <br />