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'ioQ� " SAN JOAQUIN COUNTY -- --._- <br /> . :_.G-��-.o�. II LOP <br /> '1 ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION <br /> '••' 600 East Main Street,Stockton,CA 95202,1029 <br /> UNIT IV <br /> / <br /> Telephone: Wts <br /> e: (209)468.3454 Fax:(209)468-3433 Web: M.s-ssov-aralehcj <br /> � <br /> WELL & BOPPING PERMIT APPLICATION O <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 i :: r.. ( 'a-.�L;iu.f;(r.Cross Sheet 1.c'�l't• u� City /r clQ'I' Zlp APN '2 5<:, e f c C> <br /> Property <br /> Owner f,` Address �e( Cc-f J C Y0 Ad City � (� p` c c• Phone <br /> r c <br /> 0-E7 ContraatoJA linty:,. Address I J'% I'��::i' l--�c�5 City tL' !�! '1'1< Hefi'SIG.? Phone '!71' <br /> Consultanusub Cntr 1, I" Address / i%IJ. L�di"'At City 1,1 4, �'�'"� Lic Phone C �{ ;i; 1f•F. <br /> Billable Party Address " city n _Zip Phone_ 1 _ <br /> GIS Coordinates:X 30 Y �- <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑,NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> —E7 SOIL-BORING IDs i — <br /> '.. O WELL ibs..- <br /> ❑OTHER IDs J/ <br /> TYPE&#OF VVELUBORING INSTALLATION TY'k 1 ONSTRUCTION$R CI _ - <br /> -❑MONITORING 0 HOLLOW STEM CIA.OF BOREHOLE O MULTIPLE_CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water 0 HAMMER(DRIVEN CASING THICKNESS �'-- TYPE OF CASING'. 0 STEEL 0 PVC 0 OTHER —. <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL Lin TR AIE TYPE TO BE USED: ❑AUGERS ❑HOSE 0 PIPE <br /> _0 SOIL BORING U PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM'FREE-FALLOEPTH IS 30 PT) <br /> INJECTION atrS i �\ <br /> _0 I;e Jase.i>rs�10 HAND AUGER GROUT SPECIFICATIONS '• � O <br /> _0 OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOIrED TRAFFIC BOX-'OFF RSTOOC PIPE (\may <br /> CONDUCTOR CASING❑Na 0 Yes:Casing Ok: Casing Dri11tr._ FbnnO.Qig"'-.,_A <br /> COMMENTS:__ <br /> NOTE: OFFSITE WELLS&SORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS \I� <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THATAPPL <br /> _!(S)TOec DESTROYED 1❑',OVER-BORE DIAMETER OF 10 INCHEST000PTHW=�FT <br /> WELL IDs: - ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURRnOE <br /> GROUT SPECIFICATIONS vCl Nil-i ❑EXPLOSIVES FROM TO Fr BELOW SURFACE <br /> TREMIE TYPE 1-0 BE USED:[.4 AUGERS ❑HOSE,E]PIPE ❑MUSHROOM CAP AT(>3 FT) Fr 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 aecordanae with San Joaquin County Ordinances,Rules and <br /> Roqulsr'oo,,a0d all app!Cable lifdml l <br /> Signe. <br /> oned TI::=�'u�="-� � �"� � > TitlelCompany i <br /> Print Name :i�':iC.I'i Wit'{�f--x.I=,c?�•� Date ---- <br /> DEPARTMENT USE ONLY2Q�./59� <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS SQ 2 E• �TL�ZU.1 (X.(�•r( I V <br /> WORK PLAN DARED g l/ <br /> APPLICATION ACCEPTED BY 6m AREAS�jj-- <br /> GROUTINSPECTIONBY _ FINAL INSPECT IO _ ... DATIjz-/,"/ <br /> DESTRUCTION INSPECTION BY DATE 7 <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AIO# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# P,ECV'D BY DATE SERVICE REQUEST ROPR## INVOICE Z <br /> SR# d <br /> E <br /> ---- — — PR# <br /> 2soo <br /> C-557 WC I`+VfJVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> ElID29-01 07120/70 WELL PER , PP <br /> FILE COPY <br />