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FILE COPY <br /> H( SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone:(209) 468-3147 Fax:(209)468-3433 Web:www.siaov.orafehd UNIT IV <br /> WELL & 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 fora 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$880 Ikj6ran1-1­iry PJ Cross Street Sb YoYI VA City/State'fi' "zpg93Qt)Pro _ APN 200.• ZIb•SO <br /> Owner�IV 4ig GAriloAlkii Address 357-6t�.(�ieYl)ArvtiA 1(rK Or City/StateC'jt,,µ',"n./a Zip'15ZIa Phone <br /> C-57 Contractor 00F`6040-CWP Address L016 1 01(•.�/CEQ ALCA444--ate:I{R_�10�Uc9 �i' Phone / � Z <br /> Consultant/Sub Cntr:j&A f d+ Address 5512- LAA 6",(4.1 oS Clty/StateK0ji11"vt uc Phone 9AII,- (114?•49 2 f <br /> Billable Party :Tt gra T'[Ch Address 52)2 LA LP AJ rS -Ar to CIty/State NAL Y1Zipg4�6 f?2,Phone glib-/e 43•rf824 x f2 <br /> GIS Coordinates:X 4 0 Y O 2 <br /> C NSTRUCTION WORK TO BE PERFORMED: <br /> LE NEW�LL/BORING(CPT,GTPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> SOIL BORING IDs_ Q <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE 6#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING D HOLLOW STEM DIA.OF BOREHOLE '7-'r O MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> _D EXTRACTION:VaporlWater 0HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL 13PVC D OTHER <br /> _O SOIL VAPOR PROBE D MUD ROTARY DEPTH OF GROUT SEAL TREMIETYPETO BE USED: ❑AUGERS O HOSE O PIPE <br /> _F'SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:O Yes D No(MAXIMUM FREE FALL DEPTH IS 30 FY) <br /> _D INJECTION n e Nrseema.oLmar❑HAND AUGER GROUT SPECIFICATIONS <br /> _O OTHER: O OTHER APPROX.BORING DEPTH 5-11J,54 tpAS O BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS <br /> CONDUCTOR CASING O No 13Yes:Casing Dia:_Casing Depth: Boring Dia:_ <br /> NOTE: OFFSITE WELLS 8.BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCWETION WORK TO BE PERFORMED: DESTRUCTION METHOD:rCHECK ALL THATAPPLYI <br /> $OFLL(S)TOBE DESTROYED ❑OVER-BO RE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDS: TSC7 ❑PRESSURE GROUT To DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS I P' 11 moo• 1.v� Cc'N`tri , ❑EXPLOSIVES FROM To FTBELOWSURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE PIPE <br /> COMMENTS ❑MUSHROOM CAP A7 L3 FT) Fr BELOW SURFACE <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,an#i I'RPPllcb- California laws. y-� I <br /> Signedyif� \ Title/Company_ ROX c f 1 4,z n Kf e-f%}Yg T(-1-% <br /> Print Name VR Lent t.(/t/b! Date 2/ 4pe'l ?&lq <br /> 1DEfP�A�RTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS ]S!"X-� l t�. 6011}01/I1,4— IZ/) <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY , Y e 14 fct to DATE I <br /> GROUT INSPECTION BY FINAL INSPECTION BY to <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICO NDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODER I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUES <br /> /T PR: <br /> E 125 x 5 C.ZD ®1'173 ^f•(-r+r '-) SR# V S/ <br /> 2C(O°J 37S RO# <br /> 3500 <br /> PR# <br /> z90o <br /> C-57 1/ WCWAIVER1&/W— C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT r ENCROACHMENT DOC NN <br /> EHD 29-01 5/09/12 WELLPERMMAPP <br />