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..� SAN JOAQUIN COUNTY �..' <br /> o •........ � LOP <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> y < SITE MITIGATION <br /> `• 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> lephone: (209) 468-3454 Fax: (209) 468-3433 Web:wwW.sictov.org/ehd <br /> WELL & BORING PERMIT APPLICATION <br /> �t•� F is, `;'y��li <br /> POR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> r 'iii=:'-''TH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> AK" 1' ri�; te , tD San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin Count Development Title,Ch pter 9-1115. and the Standards of the San Joaquin County Environmental Health Department. <br /> 4 E GEitl, n�sT A @@ p r` Q t _ <br /> Site Location l E• QMP s•Street y' 1�v7T City �R Zip ��3 APN 3 <br /> Property 6110c, 4 <br /> c t-Il kW— An.)'� ��nn-city p 9 9� ��r �3b I <br /> Owner Address Q UN(./'YV � lam• 0/V Zi Phone <br /> —G-SMontractor Address City Lic Phone <br /> Consultant/Sub Cntr 3TAI�TGC. Address} lAfAyL7TE GQ 7 %-City yone,/ Phone 91S 29123QQX 230 <br /> Billable Party c5('f�IIr�EC Address City Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs I n . <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN 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 ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i a.Air Sparge.Ozone l❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑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: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) q«V,477P4 TD t Z•G�t. <br /> #OF WELL(S)TO BE DESTROYED t El OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: -ZG ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TOBE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE <br /> COMMENTS FQ_ N_uEL SOLI, S .St7lL CSAS Wim? C 'i'D R,G" &40AA A RUAIAJ6, .S/TE: t%C 11,!IrTl0 <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 /> Regulations,and all ap lic a Californi laws. <br /> Signed Title/Company S T S7'24,J <br /> Print Name /V A-- RAOalV i"W Date 4 /2-010 <br /> DEPARTMENT USE ONLY <br /> ^` <br /> SITE MAP IN UNIT IV FILE-SIT ADDRESSO <br /> WORK PLAN DATED5-/Z6fto <br /> APPLICATION ACCEPTED BY �L��LGv— DAT I U AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY r."a�� & a w wv DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 7-g02 $122x i 22.0 -L Z- SR# 610 <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 WELL PERMIT APP <br />