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FILE COPY <br /> SAN JOAQUIN COUNTY <br /> LOP <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> Telephone: (209) 468-3454 Fax: (209)468-3433 Web:www.si9ov.org1ehd <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 '71C_Dgd'dOZ <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. 145_0qp-oe{$ <br /> Site Location 207,5 U. NQ� g,IkdA cross Street �AjL`Lr9 A� City.. &\a uA zip 75ZO3 APN 1145-030-06 <br /> Property /� p LLam�,, <br /> Owner Address �6 ('+K. /-� Cityt+ Ft�n Zlplql1T Phone <br /> C-57 Contractor �L Address 958G R. /413_B City .V—�.ry LirZ833z6 Phone 800-83-303 <br /> CansultantlSub CntrGN All Address �,AL �4V2 5-ketw�,' Ciry 0HC Lice IC Phone <br /> �540-547-7950 <br /> Billable Parry C14 1,11 91' 11 Address )55A A4LK 0NCiryQ'K-11 Zip TWWCr Phone!)o-591L-7 '7, <br /> GISCoordinates:Xb.;ZSmal YZ11a 1a.C7 <br /> ONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CFTeflPROOfE&CROpuNY,}I�8D f 0T R))� 1�ryy� �K <br /> SOIL BORING IDs /,11 �1L�a Ch1 ("� b -( <br /> ❑WELL IDs V <br /> ❑OTHER IDs <br /> TYPE&#OF WELLJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DW.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> _0 EXTRACTION:Vapor/Water 0 HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> 0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE ❑PIPE <br /> e.{SOIL BORING [I PUSH POINT(GP/CPT) GROUT SEAL PUMPED:O'Yes Oj,,No(MAXIh1UM1 F EE FP1l EPTH I��FT) \ ( ' ,,fl' <br /> _O INJECTION Re i,$,. e.Onme10HANDAUGER_y_(�� _GROUT SPECIFICATIONS IV(ATr✓ �er"LGx{ �0 �ar ��'t- Q•I. tr Uerf) 1) (.O�- 4 <br /> _0 OTHER: OTHER ■4 APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR 6 STOVE PIPE <br /> CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth: Borng Dia:_ <br /> COMMENTS: O <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 WELL(S)TO BE DESTROYED [IOVER-BOREDIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES mom TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS <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 /> Regale tio s, all II Ie California laws. Ln I I l <br /> Signed Title/Company GNtr' 1 HILL <br /> Print Name Abe (`e Dale -7" o <br /> DEPARTMENT USE ONLY Z?-bb <br /> yy <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS W, Cs..i1 9 <br /> WORK PLAN DATED ZO <br /> APPLICATION ACCEPTED BY DATE ISSUED 1 ' 5-tI AREA 01W <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY PATE y— p <br /> COMMENTSICONDITIONS: 01911 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PqR# <br /> ao 5 $122. 1 10 SR# 06W`15 <br /> Z4o3 /per �Z`� 2.5t<A '7 S- a <br /> y4p 3 3(0 29 0 05058 <br /> C-57 WC WAIVERel:', �}__. C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT b�ENCROACHMENT DOC N <br /> EHD 29-01 0728/10 ( � IE <br /> W PED Y <br />