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Jul, 31. 2012 11 :48AM No, 1037 P. 13/16 <br /> ,.. .- SAN JOAQUIN COUNTY <br /> m` fir` ENVIRONMENTAL HEALTH DEPARTMENT (_OP <br /> 1868 East Hazelton Avenue, Stockton, GA 55205.6232 SITE MITIGATION <br /> UNIT IV <br /> Telephone:(209)468-3464 Fax:(209)468-3433 Web:leoe w-yiaov.ora/ehd jUl �� <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVE$TIGATIONS AND REMEDIA)rION °r ITy <br /> NON-REFUNQ68LE PERMIJIFXPIRES 1 YEAR FROM DATE ISSUED <br /> Appllcadon Is hereby made to San Joaquin County for a permit to construct and/or install the work described, This application is made in compliance with San <br /> Joaquin County Development Title.Chapter 9-11153,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 10%55 _y7AAAV,0•Cross Street 11�- t- "i&t. AV f- City.LAL11_14)P Zip C153'21D APN <br /> Property <br /> Owner JMV lt pTJ2.L & 'Address tkg555 ttl N" 120- City? _zip phone <br /> C47Contractor Address OC.a HDWz 1(�AZ- City l },rI1E lac S S Phone 612-S 3{3 46cb <br /> Consultant/SubCntr O[s�t ddtiyL C11-v11rYCCity QUt4WNft-f%Lic Phone aIle q2.3•t0fi"I <br /> Billable Party R h l I f r i k W LP Address �(p.�i�d7iGUM �T City Zip qq,6i00 Phone-of ltd- <br /> GIB Coordinates:X_ _-Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> []NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> Q SOIL BORING lbs <br /> ❑ <br /> WELL IDs <br /> ❑OTHER IDs <br /> TYPE 19OFWELU13ORING INSTALLATION TYPE CONSTRUCT19NSPECIFICATIONS <br /> _©MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> —0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑$OKI BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(Le .Ozmel 0 HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH [3 BOLTED TRAFFIC BOX OR O STOVE PIPE <br /> CONDUCTOR CASING Q No❑Yet;Casing Die: CaWg Depth: Owing DIN <br /> - <br /> COMMENTS., <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> 0�0IBUr,TIQN WORK TQ BE AHED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OFW LL((S�)TOB DESTROYED Q OVER-BORE DIAMETER OF INCHES TO DEPTH OF�_FT <br /> WELLIDs: �Vv ' -f PRESSURE GROUTTO OSPTH OF ZZ; S FT BELOW SURFACe <br /> GROUT SPECIFICATIONS EXPLOSIVES FROM T4 FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ffPIPE ❑MUSHROOM CAP AT(>-3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> hereby ca"that I have prepared this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> RAgulatl an all applic Calitomia Laws. <br /> Signed Title/CompanySbqf� Qeota!r isi 1z. �i�G1ct¢cs <br /> Print Na �r-ti LO Date LPI I 1�1 112-,DEPART ENT USE ONLY p //� & <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS ��S b0 S• 6 �6 5; / <br /> WORK PLAN DATED Z� Z <br /> APPLICATION ACCEPTED B BATE ISS <br /> GROUT INSPECTION BY FINAL INSPECTION BY PATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK G RECV'D BY DATE SERVICE RO# INVOICE <br /> E, REQUEST PIR 0 <br /> 31252 o ( 17i g o04s <br /> a 375- 7 °o 68,6 <br /> PR# <br /> 2800 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />