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SAKI JOAQUIN COUNTYIk � � -- <br /> ...� 6, ONMENTAL HEALTH DEPARTMv_oT SITE <br /> LOP <br /> 600 East Main Street,Stockton, CA 95202.3029 UNIT IV <br /> ;.;� <br /> Telephone: (� ) -3454 Fax: (209) 468-3433 Web:www„S��ltarr.o�oll old <br /> IROR <br /> fjEii <br /> WELL & BORING PERMIT APPLICATION %.41P ED <br /> FOR WELLS AND BORINGS U.SEI)FOR CONTAMINANT INVESTIGATIONS ANIS REMEDIATIONjUN <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is heroby.made to San Joaquin County for a permit to construct andlor Install the wodi descrlbed. This application <br /> " . Chapter is.4r �/b j � <br /> 1 <br /> h San <br /> Joaquin County Develo rentTitle, 9-1115,3;wid the Standardsof the San Joaquin County Environmental Fleaith De artme RMTfS �vi CALTH <br /> site Location ores street ar496ica � c-Z city � c� APN /z_3 2r5t <br /> � <br /> property <br /> Owner -Twe Pit vw euwr.Wd'�'Address � j>O OOX 1,460 City. Zip Phone �� _X3 MIM <br /> C-07 contractor e� lkl.zLlAl6 Address 2Zt7 City . f:3 pa pi; a�lt Lic 'Di Phone '�C 66Sf <br /> CortsultantlSub C90 &,C-Q& .Address `16( (J jg�MIL 5 708 ty QAgLAAjk Lie A416 16Y Phone <br /> Billable Party C'4�1 b&4 Address -2 10( [Joa.5-rC_fP_j:i1 SP's 19 66Y Zip q 4Phone.�rl� <br /> GIS Coordinates,X_dj.7 S V g ' Y61 w f a l.e <br /> CONSTRUCTIONWORK BI jc-I�F{�fd�_IE�1; <br /> ❑NEW WELUBORING(CPT,GEOPROBE,WDROPUNCH,HAND AUGER,0171ER) <br /> SOIL BORING IDs <br /> WELL IDs <br /> ❑OTHER IDS <br /> 1FY�P #QP W INS_LkLLATION TYPE GQNSTRUCTION SPECIFICATIONS <br /> I _❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE ❑MULTIPLE:CASINGS❑MULTI-i.EVEL WELL CASING DIA: <br /> EXTRACTION:VaPurl Water Cl HAMMERIORIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL ❑.PVC ❑ OTHER. <br /> _l7 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL______,_• ^TREMIE TYPE To BE USEDi a AUGERS. p HOSE ❑PIPE <br /> _❑SOIL:BORING ❑PUSH POINT(GPI.CPT) GROUT.SE L,PUMPED:❑Yes ❑.Na(MAXIMUM FREE FALL OEPTI9 IS B0 1 <br /> -❑INJEOTION&E ALtBj ne gj❑HAND AUG1 R GROUT SPECIFICATIONS <br /> l _❑OTHEW ❑OTHER., APPROX.BORING DGRTH ❑.BOLTED TRAFFIC 13OX OR ❑STOVE PIPE <br /> I <br /> CONDUCTOR CASING❑No'❑Yes;.Casing ala:„Casing Depth: Boring Die: <br /> COMMENTS-, <br /> NOTE., OFFSITE WELLS &'BORINGS:'REQUIRE.ACCESS AGREEMENTS OR:ENCROACHMENT PERMITS <br /> IDE-STRUCT19N WO It:TO BE PERFQRMEM DESTRUCTION MEV. , C ECK 6LL THAT APPLY) <br /> #OF WELLS)TO'BE [)ESl'ROYEI] OVER-1306E DIAMETER OF••-,Z0 LACHES TO DEPTH OF oZ0 FT <br /> WELL IDS: 0' []PRESSURE GROUT TO DEPTH OF---PT BELOW SURFACE <br /> GROUT SPECIFICATIONS I]EXPLOSIVES FROM To._Fr_-I=r BELOW SURFACE <br /> TRi✓MIETYI'ETO BE USED:❑AUGERS ❑DOSE ❑.Plf'E ❑MUSHROOM CAP AT L>3 F7} BELOVUSURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTIICE REQUIRED (,AFTER PERMIT ISSUANCE)FOR INSPECTION APROIINTIflENTS <br /> I hetebycertify that I have prepared tftts appliciition and that the work will be done in aceordance with San.Joaquin County Ordinances,Rules and <br /> Regulations,ancl.ail pollUble.Callfolrinig laws. <br /> Signed ”` Tftle6Company i�g AI. 0v <br /> 1 Print Nome __ �Ir.9 . _ -°ld L —Date <br /> f <br /> DEPARTMENT USE OIVE�Y <br /> SITE MAP IN UNIT IV F -SITE ADDRESS Pq Sb <br /> WORK PLAN DATED �DB ; <br /> loAPPLICATION ACCE DATE ISSUED 42;hd& AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY 14A'—L4 - DATE 0'a' 20 to <br /> DESTRUCTION INSPECTICJN BY DATE <br /> CO MENTSICONDITIONS., <br /> ACCOUNTING ONLY: AID tI FAC <br /> PE CODES FEE 111IFO AMT REIVIITTED CHECKI$ RECWD MY DATE SERVICi I�(]�k INVOICE <br /> I�EQl1EST PR# <br /> l $122x - 7 �y � f r� SR# 1�"9_9?11R <br /> p y (� ppm <br /> PRS 3f <br /> 29Q0 <br /> C-57� WC WAIVER C-59 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACFIMENT DOC <br /> m4r%hoJ11 I1717fi19 n lr{ff-'1 I =MNT IIop <br /> S <br />