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t4••t+.. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> b SITE MITIGATION <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> UNIT IV <br /> a•..,- � Telephone:(209)468.3464 Fax:(209)468-3433 Web:WM/Mrsiaov.oralehd <br /> ko•a 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 for a penult to construct and/or Install the work described. This application is made in compliance Win San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location VJcc'k Akr,- -r �^Gross Street 1�'r City Zip QSZ\d1 APN \Z(' `•`�e`� <br /> Property _ I ,_ <br /> Owner '— Address - = `� City _ Zip Phone <br /> \n Cc yc A38\\0 Phone COY\jo) (038•'.51 \\ <br /> C•57 Contractor LaSpC�a� Dc:\\: Address 31032`"Or,ne..� CNC�� City �^� ° ` <br /> ConsuitanVSub Cntr f\\r ( y�{y6 Qdress I,Q(yb2 C)wc✓`S �)a Ira°City PlcnsaA� Lio Phene 0.2.5 �{Io0--S36b <br /> Billable Party me ('YSSOC:CkSA\KAddress 1-g lzb2: '01"'o3ity V, zip 4k45C38 Phone3SlUwo -!57340 <br /> GIS Coordinates:X Y - <br /> i <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT•GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) - - <br /> ❑SOIL BORING IDS <br /> ❑WELL IDs . <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA OF BOREHOLE _ 0 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> —0 EXTRACTION:Vapor/Water ❑HAMMER/DRNEN CASING THICKNESS TYPE OF CASING: D STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE O MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE O PIPE <br /> _O SOIL BORING O PUSH POINT(GP/CPT) - GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTHIS30 FT) <br /> _0 INJECTION a e A rSoaroe Ozonal l]HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: . ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR O STOVE PIPE <br /> CONDUCTOR CASING❑No❑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:(CHECK ALL THAT APPL» <br /> #OFWELL(S)TO BE gqEESTROYED OVER-BORE DIAMETERCF_'24 INCHESTODEPTHOF .5 FT <br /> WELL IDs: �t xkff- &PRESSURE GROUT TO DEPTH OF `.q0_ FT BELOW SURFACE <br /> GROUT SPECIFICATIONS - ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:t�AUC,�R$ HOSE PIPE q; ®MUSHROOM CAP A'T(>3 FT)" FT BELOW SURFACE <br /> COMMENTS MW"a lDC0. d j.y \j C• -'cy'Nk -be-V- `{� P0.S'\�obJ•+`F bin W` 4M <br /> 6'WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the workwill be done In accordance with San Joaquin County Ordinances,Rules and <br /> . Regulations,an all ppttca e C ifoIn Is Laws. Q�( /{��!� <br /> Signed �� --Title/Company YT73'\"'C Ge'A00N* f Ate- AS€S+a C\CjFeSI"A C.. <br /> PnntName - r •r�o./� ' ltc.l�w�a �'�' Date 10111.12:. <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS 3 SSS �W 1• ,Jmm a-r LQn if- <br /> WORK PLAN DATED A02,rj 17, 2o/2, .eco <br /> APPLICATION ACCEPTED BY AyI DATE ISS l✓ S9 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE 240-17 <br /> DESTRUCTION INSPECTION BY _ DATE <br /> COMMENTS/CONDITIONS: G Cr v�I —Llja-Le) <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST' PR# <br /> 35-02 S125X 1 as0 0 12-301`1 G zo R# 00(,571572, <br /> RID <br /> 35-03 37s,oD �' SlT7l s0g0 2 <br /> + S D O' 00 PR# <br /> C-57 WC WAIVER "C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />