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ORIGINAL <br /> o � SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton, CA 95206-6232 <br /> Telephone: (209)468-3147 Fax: (209) 468-3433 Web:www.siciov.oraleh `I <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIdh'' 0 4 niri <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application Is rhnde L� l �rf>f <br /> Joaquin County Development Title,Chapter 9-111.5.3,and the Standards of the San Joaquin County Environmental Health Deparrtmen;41T/,3Frgvj E <br /> Site Location `/ t Y Z�7 APN X01-10-00 <br /> (-43Z F. Rio V25 Cross Street E'• i'Aiyc�(Q CitylState zip <br /> --- <br /> 5 <br /> CA <br /> Property Giw�o 2.09 9S1-3570 <br /> Owner Lawn .` 5c-� v�� Address Cify/Stateicd�tohZip Phone <br /> C-57 Contractor t�rveaca i��; Iv,a Address Gh0 Howe RCA City/State 4- <br /> �,e Lic ' pnorregZ5-313-SKOD <br /> Consultant/Sub Cntr CsvdHo Address I1 12 La,,e 1�1'^ AYE Sv,7f 201 City/State MLic Phone Z -45.22.1.1 <br /> CA <br /> Billable Party 6Address City/State Zip Phone <br /> GIS Coordinates:X 38•O�'G�� Y _/z l"218 �Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> D NEW WELL/BORING(CPT,GEOPROBE,HYUROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs__ <br /> ❑OTHER IDs_ . <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _Q MONITORING ❑HOLLOW STEM DIA-OF BOREHOLE _ E]MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapors Water ❑HAMMER/DRiVEN CASING THICKNESS _ TYPE OF CASING: O STEEL ❑PVC 0 OTHER <br /> _I]SOIL VAPOR PROBE O MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED. O AUGERS L7 HOSE [IPIPE <br /> _[]SOIL BORING I7 PUSfi POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ❑INJECTION t e M Sows 1[7 HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER:- _ APPROX.-BORING DEPTH_ ❑BOLTED TRAFFIC BOX OR �STOVE PIPE <br /> CONDUCTOR CASING O No O Yes:Casing Dia: Casing Depth:___ Boring DIa_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS . <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCT METHOD:(cHECK L THAT 6PPLIO <br /> S <br /> (S� OVER-BORE DIAMETER OF _INCHES TO DEPTH o= �`" FT <br /> O_#OF WELLS TO BE DESTROYED 3)Wl" PRESSURE GROUT TO DEPTH OF -X, 149 FT BELOW SURFACE <br /> WELL[Ds. w -3 5 <br /> GROUT SPECIFICATIONS e°I Q 'Ifiv ea q j jb5. r V'•,: ❑EXPLOS IVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERS ❑HOSE IPE � <br /> 5x MUSHROOM CAP AT(>3 FT) �3 FT BELOW SURFACE <br /> r •, - � � wc11 y, <br /> COMMENTS�i HC�, ���i `; .-•1 <br /> r 8I1l L 92` +_ 3 , ll� <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 /> Regulationsx all applicable Ifornia laws. 1 <br /> Title/Company.- �S�V Cl n� � I C <br /> Signed _ <br /> S-C-c�l/�� � � Date d�Z_�/ <br /> Print Name S <br /> DEPARTMENT USE ONLY <br /> p� Z7;Yy <br /> SITE MAP IN UNIT N FILE-SITE ADDRESS �7 7 ftJ y Chi 1—'57 <br /> WORK PLAN DATED E 8 (b-! 'eo/S <br /> APPLICATION ACCEPTED BY ^� Y 0*< r� DATEAS <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# NM 7REE <br /> RO# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PRO <br /> :f3oX 2 ou 3�Y-is P 9/ <br /> 3 3�0 — <br /> C-57 ti WC r/ WAIVER ft/rA­_ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT v ENCROACHMENTFI DO PFa — <br /> FHn'>"i 7n41is <br />