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0 i <br /> t VIlly 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)486-3454 Fax:(209)468-3433 Web:www.sluov.ora/ehd <br /> i <br /> AI(I, ] WELL & BORING PERMIT APPLICATION <br /> cU10 �p <br /> [�\A�()NMEN T 1jfiW f{LS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> pERMIMERWES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicalbn le hereby made to San Joaquin County fora pennR to construct andlor install the work ds/cdbed. Thfa appkotion is made in compiWa wYh San <br /> Joaquin County Developrnent Tide,Chapter 9-1115.3•and the Standards o1 the San Joaquin County Environmental Heats Departrnant. <br /> Sks Locatlon 523 Larch Road Drove Street Tracy Blvd. Cm,Tracy ZIP CA 95304 APN 21220005 <br /> Prey BC Products Rental Prop LLC Address523 Latch Road Dky Tracy Zip CA 95304 Pltora <br /> Owrwr <br /> Clearwater Group Address <br /> 229 Tewksbury Avenue City Pt.Richmond Lic 799370 phom 516:307-9943/5901099 <br /> C37 ContractorConsullsnfli Drily Ami Mini a Aunda <br /> es kic. Address 4609 Russell Avenue City Los Angeles Lic SJ31 a ph. 323-9134073 <br /> Bllleble Party ^^'i Aaini6AseoriaMS lac. Adder 46W Russell Avenue Cky LosAni Zip CA90027 Phone 323-9134073 <br /> GIS.Coordkwtsa.X 6291864.61' y_2102640 76 <br /> J. v I SOIL BORINGIDSFmr(e1.aa a eat <br /> v I WELL IDs <br /> Lf OTHER IDS p ' " ^ r. <br /> TV L/ INSTALLATION TYPE CnAnaT91 u'TION SPECIFICATM pL f TveA D21t Or r 1n IW <br /> _, MONITORING , HOLLOW STEM DIA.OF BOREHOLE T 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CAST DIA <br /> _0 EXTRACTION:Vapors yi 0 HAMAIER/DRIVEN CASING THICKNESS Sch 40 TYPE OF CASING: 0 STEEL I PVC 0 OTHER <br /> .-0 SOL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL--AO Att617REMIE TYPE TO BE USED: 0 AUGERS 0 HOSE A PIPE <br /> _r SOL BORING I PUSH PONT(GPI CPT) GROUT SEAL PIIMPEO 0 Yea 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION WLA,,Saadaj=,u , HAND AUGER to 5•bgs GROUT SPECIFICATIONS Bentonite Cement Slurry <br /> _❑OTHER: 0 OTHER: APPROX.BORING DEPTH 20 feel + BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING 19 No 0 Yes:Casing Die:_C34tq D/Pth:_Gonna Oa:_ <br /> COMMENTS'. <br /> WELLS i BORINGS REQUIRE ACCESS AGREEMENTS <br /> gZjMijW=jjMj=fCHECK ALL THAT <br /> /OF (8170 BE DESTROYED OOVER-BORE DIAMETER OF INCHES To DEPTH OF FT <br /> l ❑PRESS(1RE GROUT TO DEPTH DF Er BELOW SURFACE <br /> G $PECIFICATIONS ❑EXPLOSSNES FRot4 TO FT BELOW SURFACE <br /> T TO BE USED: AUGERS HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> 5 NOTICE REQUIRED(AFTER PERMIT IB"ILIANCE)FOR INSPECTION APPOINTMENTS <br /> I hsYaby t Pns0 that sppNcstlon and that the work will be done In accordance wish San Joaquin County Ordinances,Rules and <br /> RpuYlb / B ResbM Call/orale laws. <br /> Sgned TiOM=.on4anY V <br /> Print Na 7�'rl't�s 5lacnt�S Date d TO <br /> DEPA <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 4"Z S La Y[ t R t),2 <br /> WORK PLAN DATED Y&k IQ.i 040— <br /> APPLICATION ACCEPTED BY DATE ISSUED — AREA <br /> GROUT INSPECTION BY F/4AL INSPECTION BY_ DATE <br /> DESTRUCTION INSPECTION BY DATE 8 <br /> COMMENT&CONalmot : .�Aiir 1- 04 and AR- 4nital <br /> ACCOUNTING ONLY: AID# FAC/ <br /> SE= RO/ INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK/ RECV'D BY DATE REQUEST PR# <br /> 350 $122. 1 / 22 00 /T+ 8e 7 1 $Rx 006094-7 <br /> Ro x tf <br /> 3 & a 3GG DU 3500 ? ' <br /> S rJ a2— ' 2.7,40 _g-in S Qo46919 <br /> C•57 WC WAIVER C-57 LETTER OF AIJTHORRATIoNl TO SIGN PERMIT _ENCROACHMENT D WELL RMIT APP <br /> EHO 29-01 070'!6!10 <br />