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Jul, 31. 2012 11 :46AM No. 1037 P. 5/16 <br /> SAN JOAQUiN COUNTY Sr <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> • 1868 East Hazefton Avenue, Stockton,CA 95205-6232 SITE MITIGATION <br /> Telephone:(209)466-3454 Fax:(209)468-3433 Web:www.slslov.orglehd �IT�,V�812 <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND 80RINGS USE)rOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . <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 8-1 115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location I to S o tier!�f z'(h Crone Street TC L&-"-1 e city n5AhA ZIP S 33 L' APN iy�Lf I <br /> Properly <br /> Owner tP h i t I t r S tap Address --hi? O a-n`kAVvz-,Vq— City clStt� Phone C4 5S e 3 <br /> "7 Contractor e, I OGt� jn=Q Address C%b 1 %1' e �Pd . City kAXI U imILlc rOS IPS Phone_c.2,(�; - 13 -S106b <br /> Consultant/Sub Cntr t y Address ]Q( lukvii (i 1-iA —e�tty �44_r,r4l:1huw,1W k Phone q I Lo-92-3- l n CJ`7 <br /> Blllablo Party PV611 t iP C k u Address Z(P 6PaaLA, City�aij"Mr.l ro ZIP�'I S`81`n _Phone q �c 3 3 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMEO* <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING Its <br /> Q WELL lbs <br /> ❑OTHER IDs <br /> TYPE&*OF WELU80RING INSTALLATION TYPE CONSTRUCTIQN SPECIFICATIONS <br /> MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vaporl Water ❑HAMMERIDRNEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _Q SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FLEE FALL DEPTH IS 30 FT) <br /> „_-0 INJECTION d.a.4rSoarm.Ozma1❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: __-_❑OTHER: APPROX,BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No[]Yee:Caging Me: Casing Depth: Boring Dia <br /> COMMEWS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO IiE PERFORMED: ARR111110t I17ETHOD:(CHECK A THAT nPPLYt Q.e m� <br /> 23 #OF WELLS)TO SE DESTROYED OVER-BORE DIAMETER OF­�NCHES TO DEP H OF FT <br /> WELL IDs: RESSURE GROUT To oEPTH OF FT BELOW SURFACE <br /> GROUT SPECINCA IONS EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS HOSE PIPE ❑MUSHROOM CAP AT 0 FT) F't'BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING GAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I herebythat I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Rogulatto plicable meat Laws. <br /> Signed Titlelcompany f/II �ittP[7 �I ITT 1 �(7G Gl J <br /> Print Na X4�nIIP LDaIB_ b I I <br /> DEPA TMENT USE ONLY LL y <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS Sb0 S s Ls>'� St�(�• �r�/ <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE ISSU J <br /> GROUT INSPECTION BY �+�n�F r' L FINAL INSPECTION BY nalL -7-�� <br /> 1=H <br /> DESTRUCTION INSPECTION BY DATE <br /> CO@1 MENTSICONDTTIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> tC7,0101ESFEI_INFO AMT REMITTED [CHECK 9 RECV'D BY DATE REQUESRVIC PRff INVOICE <br /> REQUEST PR d <br /> '1251 Z,3 - — L�SZ ��`-� �p Lz_ / S 00(os`�Se <br /> 0 17- <br /> PR# <br /> 2800 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> I <br />