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r <br /> '• o,,> �'( _ d SAN�JOAQUIN COUNTY • I L E COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> UNIT IV <br /> Telephone: (209)468-3454 Fax:(209)468-3433 Web:www.siaov.oralehd <br /> �I rF da'•. <br /> WELL SI BORING PERMIT APPLICATION din/ <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> n 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 $bz E,flxfwT UkE R O Cross Street NrO&T/f dlryc x2T7hcrL City Ti Zip 953 7 C APN 2 SD 2,7 a o 17 <br /> Properly <br /> Owner PytE Address Po Go 77a oo0 city 5AN FB4,yemo Z'Ip 94171 Phone g753T'S g517 <br /> C-57 Contractor 67a-c174, -D2t ZLINSi Address gSD 140v92 n City MA2TINL" Lic N RS I U S Phone qz5 313 tab dd <br /> COnaUltanV$Ub Chi 0- Address 458SPACRE LP lStrD 5-TE Zsa City Mkt-1 RE Z. Lic 7 4 2 7 phone 975/9U9. OISb <br /> Billable Party EILa� Address 4S8S Tft)16 Co W2 S1E UO CRY 6A9,11IU Zip 94-55 3 Phone 9 01Sd <br /> GIS Coordinates:X 37 .7 4X Y-12I.41(a <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELUBORING(CPT,GEOPROSE,HYDROPUNCH.HANDAUGER.OTHER) <br /> SOIL BORING IDs P6141 /3 AotV jPGi�l'1 '9 S 011. W111-11- <br /> •q�lo -Ao1Z;Pch;3,/4r SiG -Aoi3 <br /> WELL IDs <br /> ❑OTHERIDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _O MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE n�Vp ❑MULTIPLE CASINGS 0 MULTILEVEL WELL CASING DIA: ifs <br /> _0 EXTRACTION:Vapor/Water 0 HAMMER/DRNEN CASING THICKNESS TYPE OF CASING: ❑STEEL PVC OTHER O! <br /> O <br /> ._mI SOIL VAPOR PROBE 0 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS 0 HOSE 0 PIPE <br /> r�W 1 <br /> ?- SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS <br /> _O INJECTION t..."Soaaa 0. (.A/HAND AUGER GROUT SPECIFICATIONS ? Y1{ d I0ANLA i W 1 5a/. �'jG 0Y.,� <br /> _O OTHER: W OTHER: CAEObapSCl@/—APPROX.BORING DEPTH 'S' 1 0 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> i CONDUCTOR CASING 0 No 0 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:(CHECKALLTHATAPPLY) <br /> #OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF Fr <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS I]EXPLOSIVES FROM TO FT BELOW SURFACE -� <br /> TREMIE TYPE TO BE USED:E )AUGERS 0 HOSE ❑PIPE ❑MUSHROOM CAP AT L?3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> i <br /> I hereby certify that i ha v pr pared this p6laatfon and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,a a 4C�iifd a s. - <br /> g //t7s�/r G /C�/ (/!•/�/�i <br /> Signed l� _ * TnIPlCompany <br /> Print Name !- Dale - Z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED 1 ZY ZO I I <br /> APPLICATION ACCEPTED BYAREA Q 6 P� <br /> 1 It'll <br /> GROUT INSPECTION BY FINAL INSPECTION 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 PRO <br /> (i <br /> $122, I v' •• 4C/N61cK SR# 66`Z6! <br /> 10 <br /> oao 4-q/ �7 <br /> Q �An 36G (29R 009 528CPO 5 <br /> C-57WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> END 29.01 0728110 WELL PER IT APP <br /> FELE---SOP-Y <br />