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Aulry � SAN ,JOAQUIN COUNTY Ol� l [� E �VRL,"• HEALTH LOP > — ENVIRONMENTAL DEPARTMENT SITE MITIGATION w: 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV • Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www gOY Oraleh -- [/FC WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,is made the d. s applicatio JoaquintlCount),Development Title,le/IChapter 9-1115.3,and hoaquin County for a e Standards to cof theSanor Joaqu n work Environmental nmenitall Health Department. compliance7---X(tP-�R� .�<I�2YCN I�cGL • -y2LC rV�L ' citylState / Zip JC30 APN /v ' 091 Site Location cross Street 9,z� 77 /4z 39-0690 Property �2r 0✓�/6 rut9 ��GZSSeCity/Stale ",� 7/� �--�,,ZI,�ip Phone /- Owner_ /1 / ddress �i �534 (,Phone *3 - zt3 Y/ Address ;��/ nom" Pel' ✓t City/State C-57 Contractor Lic :215:71T Phone- G 210 Consultant/Sub Cntr d ri a,Y(Cyy/�g},�'�ss ,��,1�� ,�/ >1N R�'�!�t�l city/state l�[,gto Billable Party 0 Redress a0jL�c K ' ; +--=q City/State V �Zip 9 n� Phone GIS Coordinates:X Z 7 2 ' �0Z CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE _ ❑MULTIPLECASINGSOF ISI0 MULTILEVEL ❑PVC CASING DIA: _ ER _I]EXTRACTION:Vaporl Water ❑HAMMERIDRIVEN CASING THICKNESS _DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [I AUGERS ❑HOSE ❑PIPE _[I SOIL VAPOR PROBE ❑MUD ROTARY _[I SOIL BORING C1 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes 11 No(MAXIMUM FREE FALL DEPTH IS 30 FT) zone)❑HAND AUGER_ GROUT SPECIFICATIONS __[I INJECTION f^ A S� o� [I BOLTED TRAFFIC BOX OR ❑STOVE PIPE _❑OTHER: ❑OTHER:_ __ APPROX.BORING DEPTH - CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth:_ Boring [)!a:—COMMENTS. _ - _------------ ------ IRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS NOTE: OFFSITE WELLS 8 BORINGS REQU DESTRUCTION METHOD'ICHECK ALL THAT APPLYI DESTRUCTION WORK TO BE PERFORMED: g.OVER-BORE DIAMETER oF__.g__INCHES;O DEPTH OF Z O FT #OF W ELL(S)TO BE DESTROY _A„/ PRESSURE GROUT TO DEPTH OF 3 -5 FT BELOW SURFACE WELL IDs: /Y/�V //,i'✓ ❑EXPLOSIVES FROM TO FT BELOW SURFACE GROUT SPECIFICATIONS I7 'CCL C2 m�/J9 MUSHROOM CAP AT(>3 FT) 7 �+�FT BELOW 5URFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE X PIPE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS aquin County Ordinances, Rules and I hereby certify that 1 have prepared this application and that the work will be done In accordance with SanJo Regulations,and all applicals California lays. Signed Title/Company Print Name --/i/ SDUD/ Date � - (7—.2011E — DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 4u 1 ago r/ Rog(2, Tp-';Of Q WORK PLAN DATED_ k'11/4'1 16 zef[l DATE __?.REA /& J ,J ye 4. APPLICATION ACCEPTED BY G FINAL INSPECTION BY ATE�7! GROUT INSPECTION BY DESTRUCTION INSPECTION BY DATE— DESTRUCTION DITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE L/ REQUEST PR# qq �� 7'3'1 1• $125 x SR#3500) 7CX> E�35Z�Z z 2S RO# 3”o3 PR# 2900 C-57 ✓ WC ✓ WAIVER N C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT r-- ENCROACHMENT ELLDOC ERMIT APP EHD 29-01 5109/12