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FILE .COPY <br /> P-AA SAN JOAQUIN COUNTY LOP <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION <br /> UNIT IV <br /> 600 East Main street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3464 Fax (209) 468-3433 Web:www.sE_qov,orglehd <br /> WELL & BORING PERMIT APPLICATION <br /> � <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION C-()!5 q <br /> /10 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED " <br /> Application Is hereby made to San Joaquin County for a permit to construct andfor Install the work described. This application is made in compliance Wth San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County EnVironmental Health Department, <br /> Site Location HAI-14 45,1�lt Cross Street oq�.� ",o I city IQ-yckkki zipYjQLT— APN <br /> Zip Property IV, 5rk�_ Addre.- <br /> Owner r7� — Llc1_1_06f) EPh01nn%e17!07!�3 <br /> C-67 Contractor &_� Address <br /> ConsultantSul Cntr Address 3-�' -.ran ApAycity cAce4"n Lie Phone <br /> /6 <br /> Billable Party< Address city 4,ke(Apne2:te Zje�'7�Php'ne9Z6_4FJ_�'_S_' 1i633 <br /> GIS Coordinates:X ?aq2!� Y 2,( <br /> j 1 11 <br /> CONSTRUCTION WORK TO BE PERFORMED: R,OTHER) <br /> Ej NEW WELLIBORING(CPT,GEOPIRUBE,"YUKUl'u"IH,1A111 ­ <br /> 1 <br /> 0 SOIL BORING IDS <br /> E]WELL ID <br /> LI OTHER ID <br /> TYPE&It OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _O MONITORING 0 HOLLOW STEM DIA,OF BOREHOLE [3 MULTIPLE CASINGS E]MULTILEVEL WELL CASING DIA! <br /> _EI EXTRACTION:Vapor/Water 0 HAM MER/ORIVEN CASING THICKNESS TYPE OF CASING: LI STEEL 0 PVC Cl OTHER <br /> 0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEALTREMHE TYPE TO BE USED C AUGERS 0 HOSE El PIPE <br /> [I SOIL BORING 0 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:D Yes E]No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _[I INJECTION TeA os,,.j 0 HAND AUGER GROUT SPECIFICATIONS <br /> �S [I BOLTED TRAFFIC BOX OR [I STOVEPIPE <br /> _171 OTHER:— El OTHER APPROX.BORING DEPTH <br /> CONDUCTOR CASING L1 No 0 Yes:Casing Dia:.Casing Depth — Spring Ola <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMIT'S <br /> �1.*L>. DESTRUCTION METHOD:(CHECKALL THATAPPLY <br /> DESTRUCTION WORK TO BE PERFORMED: ;RU <br /> �#OFWEUL(S)TODE DESTROYED - OVER-BORE DIAMETER OF INCHES TO DEPTH OF_Z5FT <br /> WELL IDs: E]PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS <br /> El EXPLOSIVES FROM TO YT BELOW SURFACE <br /> FTBELOWSURFACE <br /> TREMIE TYPE TO BE USED 0 AUGERS��EJ.HZOSE Lj WPI E& USHRO > <br /> COMMENTS - I 'W!, &L <br /> =� EC„ <br /> 5 WORKING DAY-8 NOTICE REQUIRED(AFTER ER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby certify the 11 'vprepared his application and that the work will be done In accordance with San Joaquin Cou ty Ordinances, Rules and <br /> Regulations,an a a California laws. <br /> Signed Title/Company r 6n co 1!�2 -,s 4— C C <br /> Print Name -6-4 Date <br /> DEPARTMENT USE ONLY,,, <br /> SITE MAP IN UNIT IV FILE-SITE ASY2, <br /> SS <br /> WORK PLAN DATED 0 , <br /> APPLICATION ACCEPTED BY DATE ISSUED <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE, <br /> DESTRUCTION INSPECTION BY DATE 1 f <br /> COMM ENTS/CON DITIONS: <br /> ACCOUNTINGONLY: 9 AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR## <br /> 3go 2- 5127x SR#00(0te <br /> O# <br /> ku R <br /> ENCROACHMEN7DL4 <br /> C-57 WC _%Z�WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT TE L'EO 4 <br /> EHD29.Oi 07J28110 <br /> FILE COPY <br />