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SAN JOAQUIN COUNTY �1 <br /> "6 ENVIRONMENTAL HEALTH DEPARTMINT <br /> _E P UP y <br /> ' 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> �LrFORN` <br /> Te/ephone: 209 468-3454 Fax:(209) 468-3433 Web.' www.sin�nQlend UNIT ly <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 Coin ' Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department, <br /> Site Location L nr�� va /,• (�auF,'� A e. -4 <br /> Propertytjn,,h K Cross Street BQ„-„ /y�f Ar Ci Sf%GK <br /> Owner ,`VPC(Wj4 L7U c/p city t'Dn ZiP--iL2-0?-_ APN <br /> Address ��+( [�ti/ rt4,k, City S»7r}D <br /> C-57 Contractor j�(�-� Q ZIP�]�7 Phone L205�F,- "D <br /> Address _lI SSD M 'o- gt/k Q) City p.Lth e Cafdw <br /> (;Gable arty Cntr"4,A r �,,_yj C )c� ft�gl M c J.i —r` / -L.Ic -1112L9154PhoneLiLl J-;_gc( <br /> Address I City ►$'ill 4r9 <br /> Billable Party 6eWynle( u'fl Lic Phone /Cq/6C )_ /_ >37-E6 yo <br /> Address d <br /> GIS Coordinates:X X_ Q p�?Y _�Z/ City ,FpG ak -) Zip 4C�h ';-p phone 1SP2 ) <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> Q NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHE <br /> [3'SOIL BORING IDs SC- -/O <br /> ❑WELL IDs <br /> ❑OTHER IDS <br /> TYPE&#OF WELUBORIN 3 INSTALL— CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM <br /> ❑EXTRACTION:Vapor/Water DIA.OF BOREHOLE )� ❑MULTIPLE CASINGS 13 MULTI-LEVEL WELL CASING DIA: <br /> r� ❑HAMMER/DRIVEN CASING THICKNESS <br /> "7 9KSOIL VAPOR PROBE ❑MUD ROTARYTYPE OF CASING: ❑STEEL ElPVC ❑ OTHER <br /> Q' <br /> —E]SOIL BORING DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: El AUGERS POINT(GP/CPT) GROUT SEAL PUMPED'❑Yes ❑No(MAXIMUM FR ❑HOSE ❑PIPE <br /> _0 INJECTION(ia Ar S Ozone)0 HAND <br /> AND AUGER EE FALL DEPTH IS 30 FT) <br /> _❑OTHER: GROUT SPECIFICATIONS <br /> � 13 OTHER: APPROX.BORING DEPTH .J� <br /> ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: I CONDUCTOR CASING[]NO❑Yes:Casing Dia: Casing Depth: Born Di <br /> T mOdran T� ✓)/a�nl� /aC A�nhn� g <br /> NOTE r,« .�dw <br /> vveLt S BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK 70 BE PERFORMED: <br /> #OF WELLS)TO BE DESTROYED DESTRUCTION METHOD: CHECK ALL THAT APPLY <br /> WELL IDs: ❑OVER-BORE DIAMETER of <br /> GROUT SPECIFICATIONS ❑PRESSURE GROUT TO DEPTH of INCHESTO DEPTH OF F7 <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑EXPLOSIVES FROM FT BELOW SURFACE <br /> COMMENTS ❑MUSHROOM CAP AT > TO FT BELOW SURFACE <br /> L3 FT)—FT BELOW SURFACE <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and alta 1i ble Calif i <br /> aws. <br /> Signed <br /> Print NameTitle/Company 7,&Vi'0,-,/. (�CcS�si fG <br /> .rl�sS <br /> Date 1_,141 /� <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS DEPARTMENT USE ONLY <br /> 4Qr k'09 F� 0&CV /'04r- <br /> 2CIM956? e 6, Z6 WORK PLAN DATED Z <br /> APPLICATION ACCEPTED BY - <br /> GROUT INSPECTION BY DATE I /G 9 <br /> DESTRUCTION INSPECTION BY FINAL INSPECTION BY DATE '/3•,' <br /> COMMENTS/CONDITIONS: DATE <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMT REMITTED FAC# <br /> CHECK# RECV'D BY DATE SERVICE RO# <br /> G REQUEST p{t# INVOICE <br /> IU $125x / lZ .-GZi Y8L1O4 J <br /> 2” ��/ SR# � <br /> RO# <br /> 3500) <br /> C-57 _ WC _WAIVER—A.1�- - C57 LETTER OF AUTHORIZATION TO SIGN PERMIT �i 2900 ACHMENT DOC _ <br />