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RECEIVED S301A83Sd1V483d <br /> '-+d' 141IV3H�d1N3WN0a111N3 <br /> UG 27 2012 <br /> ZIOZ L <br /> ENVIRON EAI.TO SAN JOAQUIN COUNTY <br /> PER S ENVIRONMENTAL HEALTH DEPARTMENT <br /> Q:.., <br /> 0, t SI E MITIGATION <br /> 1868 East Hazelton Avenue, Stockton,CA 95205-6232 UNIT IV <br /> •.- Telephone:(209)468-3454 Fax:(209)468-3433 Web,www.s*ciov.org/ehd <br /> c �a •� <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 and/or install the work described. This application is made in compliance with San <br /> Joaquin County/Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location G 232 1-:, / b O Cross Stroet I'S 1 tf_ ^r/cf t 11- City 5 4ZA 41 Z(11 '154/7 APN 10110001 <br /> Property r <br /> Owner Lci' e Sc,wat ✓r'tio Address City S1u�� �, Zip SSz 1 r Phone 40'7 931--37 <br /> C-57 Contractor FG <br /> A Address 11;SO tle�ale. '-,_✓b 'ia'r City Phone 9l6-W3-b010 <br /> ntrGConsuitanUSub Address ,? City / tajPS ZJ <br /> Llc Phone 2-02 72"2( <br /> Billable Party_. Address City _Zip Phone <br /> GIS Coordinates:X Y <br /> NSTRUCTION WORK TO BEPERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND•AUGER,OTHER) <br /> I�SOIL BORING IDs <br /> _ $G�� 5Cr- 5rr'� <br /> ❑WELL IDs <br /> ❑0'I HER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING El HOLLOW STEM DIA.Of BOREHOLE 7-t� ❑MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA: ] <br /> _❑EXTRACTION:Vapor/Water ElHAMMERIDRIVEN CASING THICKNESS _ TYPE OF CASING: ❑STEEL ❑PVC�OTHER 7eY1'o� <br /> SOIL VAPOR PROBE O MUD ROTARY DEPTH OF GROUT SEAL:N�TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _E1 SOIL BORING 11PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(I.e.AirSaama Ozoiel❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH / <br /> ❑BOLTED TRAFFIC BOX OR El STOVE PIPE <br /> CONDUCTOR CASING No❑Yes:Casing Ola: Casing Depth: Boring Dia: <br /> COMMENTS:..TC-1f)<34✓- 1� �I; H ty,.. ' 9 1_ Ph? <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION.METHOD;(OHECK ALL THAT APPLY) <br /> #OF WELLS)TO BE DESTROYED O OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: __ ❑PRESSURE GROUT To DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ___ ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <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 he done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,a $c able California Laws. fA � <br /> Sfgned Title/Company �Tg1T C"t��dQ';37 14T,-,- �OCt-;f2 Y <br /> PrinlName J,--, (���. pt�� Dale 2BIZ <br /> DEPARTMENT USE ONLY ,p <br /> SITE MAP IN UNIT IV FIL J i ADDRESS 6 7 31 gq a F8 40c k{p„� L F r SIA, tV-/. IUP <br /> WORK PLAN DATED 1 � �Z- <br /> APPLICATION ACCEPTED BY - ---_ DATE ISSUE9 D(y AREA 9 7 <br /> GROUT INSPECTION BY FINAL INSPECTION BY _ DATEdt._" <br /> DESTRUCTION INSPECTION BY _ DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAG# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> y y REQUEST /PR# <br /> 7 S $125x 125 ' 12—'FqI /'- SR# <br /> 375�� Roo 55 I <br /> PR# <br /> 2900 <br /> C-57__ WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT_ ENCROACHMENT DOC <br />