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i <br /> . '"• SAN JOAQUIN COUNTY , a <br /> ` ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> ":•� SITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> �'•: Telephone:(209)468-3147 Fax.(209)468.3433 Web:www.sI gov.orrl/eh <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 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. <br /> ' Site Location 40A STAVS_ i�r:•I ugly Cross Street CltylState Lt;A i,CA Zip I-r,2No APN Ot/7•ISo-0 <br /> Property <br /> Owner A/P'I n Aft -lpfsn AddressOr,< ToRNspr.61 Wal City/State .fork Zip S,] Phone_060) .3bT-3gel, <br /> C-57Contractor Address4s J_ SnAVsi-riei tiva� City/State-I rd, ra_Uc LL.c�Phone (3as)30!i q <br /> ' ConsultanVSub Cntr Address I �� CltylState Uc Phone <br /> Billable Party M1rv'Io Io. An�d'i Address *X Ln,IkStYi CI Wqq City/State 1�,!JcX Zip `r5,0a Phone <br /> GIS Coordinates:X 37,9091 Y "121 ,2e'5 . <br /> ' CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELU130PJNG(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs I <br /> ❑WELL IDs I <br /> ' ❑OTHER IDs i <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> ' _O EXTRACTION:Vapor[Water ❑HAMMER]DRIVEN 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: ❑AUGERS 0 HOSE ❑PIPE <br /> _0 SOIL BORING 0 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION 0,NrSaaoa.Omne10HANDAUGER GROUT SPECIFICATIONS <br /> ' _O OTHER: 0OTHER: APPROX BORING DEPTH O BOLTED TRAFFIC BOX OR OSTOVE PIPE <br /> CONDUCTOR CASING 0 No 0 Yea:Casing Dia: Casing Depth:_Boring Ole:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> ' DESTRUCTION WORK TO BE PERFORn D: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> A�#OFWELL(S)TOBE DESTROYED OVER-BORE DIAMETER OF, r _I NCH ES TO DEPTH OF.S.S FT <br /> WELLIDs: 644 R PRESSURE GROUT TO DEPTH OF- --40 Fr BELOW SURFACE <br /> GROUT SPECIFICATIONS I' PLOSIVES FROM TO Fr BELOW SURFACE <br /> ' TREMIE TYPE TO BE USED: AUGERS HOSE PIPE ❑MUSHROOM CAP Ai(>_3 BELOW SURFACE <br /> COMMENTS W°IK U1,11 17z n"� 111 +n'f Srl �� f7tirnlw^Fr'f' At�l�r vS+r WLr.-MA AI' 4"r,--mac F <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> ' 1 hereby certify,t ve preparod this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, all pl ��aayyJJ' le c ifornla laws. <br /> Signed —� "� TitlelCompany �2� Nati O. iT^c��' e--r Y•9R"a <br /> Pdnt Name /' ' /0�rw"y Date t �✓r� <br /> ' T DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IVFILE �6Z �/VnNIY' i %KL. [�A'r�. <br /> WORK PLAN DATED �t l/ 54NG <br /> APPLICATION ACCEPTED BY } It4C#!1G O1S1r/!*0ffi DATE ISSUED; 5'1Z9014 - AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTS)CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> �dZ 5125X Z- -47-5'0 L11-40-191 14111 SR# 69' 300 <br /> z°ld 77S X75 RO# <br /> 3600 <br /> ' lr2y <br /> PR <br /> C-57 V WC WAIVER N C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT NiY ENCROACHMENT DOC N <br /> EHD 29-01 6/09112 WELL PERMIT APP <br />