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ip <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> Telephone:(208)468-3454 Fax:(209)466.3433 Web:wW slaovom/ehANELL & 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 5-1115.3,and the Standards of the San Joaquin County Environmental Health Department <br /> Sita Location t4°ll1 a 41w; I. Cross Street City t a`: lip°152"-10 APN 00-160-25 <br /> Propertyo 7Jpg52! Phone <br /> Owner 5 a14 I.Vi A LiA,..of Address \4°t-I l ►1 1a1w; CRY <br /> C.57ConVact0r- I 'ny "n 2�( X--FVdres 301/ T✓r%-h nd(wrs City /4d2I L'I: 059'70 Phone 93i-662-6-QV <br /> Consultantisub Cntr SflG Address 0115 R+vsA21 J-e ^�'2� Cfty Paco ue°1Se1�4fe Ptwne4o.�5-23q-4"152 <br /> BlllablOParty 1504- - Address A'96 Q.Ltr+^0.r 'd° 'Lt CtyQag- fAa.bAC%7ipg3444 Phons%2!i `ilq-�t'152 <br /> GIS Coadnates:X 1S 005�'� <br /> C STRUCTLQN WORK OBPEERORED: <br /> BORINDCPT NEW WELU ( aHYD P <br /> CH,HAND-AUGER,,OTHE4 <br /> E(SOIL BORING We ehr 1 <br /> ❑WELL IDS <br /> ❑OTHER IDs <br /> TT`pg&$OF WELLr90RING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _ n MONITORING Q HOLLOW STEM DAA OF BOREHOLE 1P!r - O MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DUl• <br /> _❑EXTRACTION:VaPDd Water ❑KW14ERIDRIVEN CASING THICKNESS TYPE E TYPE OF CASING:TO Q S USED: [PVC 0 OTHER❑HOSE p PIPE <br /> _❑SOIL VAPOR PROBE [3 MUD ROTARY DEPTH.OF GROUT BE y�� <br /> GERS <br /> 3-�SOIL BORING (!J PUSH POINT(GP/CPT) GROUT SEAL PUMPED:13 Yes R(No(MAXIMUM FREE FALL DE <br /> _C3 INJECTION a-,q-9nO1n' •+ OHAND ANGER GROUT SPECIFICATIONS L'-i A� <br /> _❑OTHER: ❑OTHER: APPROX BORING DEPTTH ✓LR O SOLTEDTRAFFIC BOX OR ❑STOVE PIPE <br /> C NDUCTOR CASING CJ NQ❑Yw:Casing Dia: Casing Depth: n is <br /> COMMENTS: -3 S.v <br /> NOTE: OFFSITE WELLS 8 kWNGS REQUIRE ACCESS AGREEMENTS OR ENCROJOHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: 0 OVER-BORE <br /> ION METHOD•rOHECK AfL THAT APPLYS <br /> #OFWELL(S)TOBE DESTROYED ❑OVERBORE DIAMETER OF INCHES 7o DEPTHOL FT <br /> WELL IDs. ❑EXPLOSPRESSURE. FROM TO DEPTH OF FTEELOWSURFACE <br /> GROUT SR T'of. I fiwnr _ ❑EXPLOSIVES nxoM TO FT IIELO SURFACE <br /> TREMIE TYPE TO BE USED!❑AUGERS ❑HOSE PIPE ❑MUSHROOM CAP AT�3 FT)-- <br /> COMMENTS eELow SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REgUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done In aceordence with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applICA10 Calffornla Laws. <br /> 1 .� - TitarcDmPany.�j�ck-- raa�_h <br /> Signed <br /> Print Nem )e�� ` la\1C�r"— Data <br /> p DEPARTMErNT U ONLY r� �U 1 uS t <br /> SITE MAP IN UNIT IV IFILEITP RIESS %I 1 7� L-- �'UWORK PLAN DATED /APPLICATION ACCEOAT ISSUED b old L AREA <br /> GROUT INSPECTION BY FINAL INSPECTION B DATE U I L <br /> DESTRUCTION INSPECTION BY A/I DATE <br /> COMMENTSICONDITIONS: �; LY <br /> ACCOUNTING ONLY: AID# _. FAC# <br /> SERVICE RO# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PRO <br /> INVOICE <br /> q05 $125x 2� SR#0 bySw <br /> -FW OP <br /> �� c. y 568 <br /> 03 <br /> t u PR# <br /> �b 3 7� 2 <br /> G290D <br /> 67 WG WAIVER C57 LETTER OF AUTHUR—LUTION TO SIGN PERMIT ENCROACHMENT DOC <br />