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P +++ SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP I <br /> SITE MITIGATION <br /> 1568 East Hazelton Avenue,Stockton,CA 95205-6232 <br /> • p Telephone:(209)468-3454 Fax: (209)468-3433 Web:www.sinov.ot'n/ehd UNIT IV <br /> OR� <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 w San Joaquin County for a permit to construct and/or install the work described. This applicatlon 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 DD- �rt <br /> e�partment.C'U ! <br /> Site Location 3555 WtSt !\`Gv�C..Cross Street (�G�C\4�P-SS ?c City 5t�-V� zip,q� APNOT ( e)D" <br /> Property <br /> Owner :'� N�Ikojll Address -\0.1l\ 'bw NOC K1l<..W— cry P\OUA��ny(�OGIp_ 40y�Phone e�1U)G�S-ZZ$J� <br /> C-57 Contractor Ca'x6k6C_ Address 3(0,6L J0'\kec. cy6t, city Rewclo COc[�`-yL�.c...�13a\\D Prone CA 1�)(n3`b—�(Dl1 <br /> Consultanusub Cntr l�TG- {�5^�CC\0._ Address (OUtZ OWCJN3�c�\lbO Cfry \ems \� Lic Phone �W LS�yLOCr-s3b0 <br /> Billable Party ATC -Address(p(t07- OJ :1)cAliIOO City Zip `-(y5!b$ Phone Co1LS) -S300 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHERIDS <br /> TYPE&#OF WELLISORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA OF BOREHOLE _ 0 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING OIA:— <br /> —0 EXTRACTION:Vapor/Water 0 HAMMERIORrVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> _O SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION ne A,Somas O¢ooel❑HANDAUGER GROUT SPECIFICATIONS <br /> —1:3 07HER: ❑OTHER: - - APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING 0 No 0 Yew 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: iii, DESTRUCTION METHOD:ICHECKALLTHAT APPLY1 <br /> #OF WELL(S)TO BE DESTROYED �OVEft-BORE DIAMETER OF INCHES TO DEPTH OF�___Fr <br /> WELL IDs: i�\W--\� MW-zta\w-S rMW- +MW-S'�taW-.\\ PRESSURE GROUT TO DEPTH OF Mrx 3D FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To - FT BELOW SURFACE <br /> TREMIE TYPE TO I BE USED:❑AUGERS HOSE mac[PIPE ' I Pdm SHROOM CAP Ai 43 FT) FT BELOW SURFACE <br /> COMMENTS (O (\J�[.c5 •$ \ 04 M\n 33- \nL J" o UJCC- c \� UJ\\ �WC.1\C <br /> &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, all plica al tornla Laws. <br /> Signed � �� TltlelComParry 5EY\t1< 11f1➢IL7ri\5i} /� _ 1�SS¢L�[AS) InC . <br /> Print Name_ fA, aon+ F 1(C.�e-(�4l '' Date I I I I )-z— <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS SSS KV <br /> WORK PLAN DATED aQ 12— <br /> APPLICATION ACCEPTED BY DATE I <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE `fI^( `L <br /> DESTRUCTION INSPECTION BY 'II' DATE <br /> COMMENTS/CONDITIONS: S r W- -Z <br /> i <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST -PR#5'b 2- $126 '75-0, 60 123 09 G-20 z- SR# 0065 s <br /> 3 So 3 '"31U. oo r�' S 0 s o0 4z7 <br /> o �l 2 S.UO PR# <br /> 2900 <br /> C-57 -WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN.PERMIT ENCROACHMENT DOC <br /> ij <br />