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FILE COPY <br /> ° SAN JOAQUIN COUNTY <br /> 2 _2 ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> < SITE MITIGATION <br /> .' 600 East Main Street, Stockton, CA 95202-30290 Ir <br /> UNIT IV <br /> q °. Telephone: (209) 468-3454 Fax: (209) 468-3433 Web. warw.siaay.BrQ <br /> /FOR <br /> WELL & BORING PERMIT APPLICATION �f <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDA TIJ 201 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE NVIRONM <br /> ENT <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicati ," t M41.1(ti San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Deppa metSNC CES <br /> 3 2 50 atesF t'.c,.'"%Cr- 10'..E., <br /> Site Location Cross Street 4-dV A e..V R._ City Zip APN 0831 -400 -U9 <br /> Property `, <br /> Owner -v cn.�Address 124;0 �t.SE NSC' . tx E..,City S}oc•1l.rc . Zip 9Phone <br /> C-57 Contractor Address <br /> ? RI. City Lic 5SO <br /> Z334 Phone5-106166 ��2L( <br /> Consultant/Sub Cntr SN-cr_%,vS ev%V. Address 330 Cc> e�h... ?n-� DC.City �tm�L�.. i,_�hone 6- to Ec�L <br /> Billable Party Sk-IwIvS Ivr.y. Address 33� C..o.n Ia.n P�iC I��.Cit Y <br /> C y�isw+alo.. drICZip a� , _Phone 6T(e (nCJlJy <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEIN WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ®WELL IDs —L <br /> ❑OTHER IDs <br /> TYPE&n OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> o . <br /> _(]MONITORING HOLLOW STEM DIA.0=BOREHOLE U.�/ MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _E] EXTRACTION:Vapor/Water [DHAMMER/DRIVEN CASING THICKNESS 67. i r Y� TYPE OF CASING: ❑STEEL PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL _TREMIE TYPE TO BE USED: WAUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes X'No(MAXIMUM FREE FALL DEP T H IS 30 FT) <br /> �®INJECTION(i.e Air Soaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS ^ <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH e( � _ BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING Sa'No[IYes:Casing Dia: Casing Depth: Boring Dia: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> .OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER of INCHES TO DEPTH OF FT <br /> WELL IDs: <br /> O <br /> GROUT SPECIFICATIONS El <br /> GROUT TO nEcru OF CT CI O�nr SURFACE <br /> ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE <br /> COMMENTS ❑MUSHROOM CAP AT(>3 FT) FT B=LOW SURFACE <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have pre ared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and II cable is laws. <br /> Signed Title/Company SA r.� S t.i s„�1r.S�- /$}��*� S H NJ <br /> Print Nam IQa/� w�X Date �aG�� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 3 2. 5-0 We,S t Nit m en t✓r- Lan c <br /> WORK PLAN DATED J Uri e- 22 . _-z 0 /0 <br /> APPLICATION ACCEPTED BY I e DATE`ISSUED .2 4 / AREA <br /> GROUT INSPECTION BY Yjc 6y-jA m��a FI AL INSPECTION BY V DATES-$ !� <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: Trt t +;U f r! 0 3 0 z +l 5 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHE,C/K# I RECD BY DATE I SERVICE i PR# <br /> � INVOICE <br /> 3J�0 S 122 xI B,o6 I 7 2 / SR# 0 <br /> S63 14( 3b6'6'9 �G�.0—dR o0 709 <br /> 85 .6 IPoo) <br /> C-57 WC WAIVER C-57 LETTER,OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07128/10 <br /> WELL PERMIT APP <br />