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; uIy FILE COPY <br /> AN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH r9DEPARTMENT�T Lo <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> 4LiFOPNP Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:www siaov ora/ehd n"•:WMiT IV's <br /> WELL & BORING PERMIT APPLICATION p �'" <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION FEB 19 2011. <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 matte(. •C'aij�UitE1C1'!�roitY.�SaiSnLTI'% <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. r <br /> site Location f 0 o W f3e�r%..,rn HIFDr '44= <br /> �C 4Vt C PEMMT ICES <br /> Property Cross Street W <br /> owner rty Lb,c l� r bp"a`s 17 p cio Be nja-l�l� city '(tpa .n zip f 20 APN <br /> CIMS _6r.. OE n•,_. . 4 ,. Address 3-ft/ LiANh CC',, {,Q <br /> D-57 Contractor S�(-N .n,.r C / city Shr KR, zip 9520? Phone(4) 7cQ-92cp <br /> Address 11356 Mann,- bask p/ City kLch 0 /�V,/r,-0.ic .rn'�S <br /> .onsultantlSub Cntr Ob b9 Phone(9/6)_ gT3-�n/D <br /> lo:;(�� � Address 3oy3 (' {�( / n. .v,1C. <br /> 3illable Party )City ^ Y k Lic Phone <br /> Address /5eo li j7ovp) City (� Q,fr.!e 5 Zi b <br /> 31S Coordinates:X Z Q, 0 10 y —121,323 ---3—T p1-+-rr•-z�Phone <br /> CONSTRUCTION WORK TO 8E PERFORMED: <br /> NEW WELIJBORING(CPT,GEOPRQBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> I�"SOIL BORING IDs�[ gt; -12/ S( -13 SL /`� Ski-/S` CC+lb. ,5 .-17 CC -Ir� Sr /Q1 <br /> E]WELL IDs --- <br /> ❑OTHER IDs <br /> rYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE 11rr <br /> _❑EXTRACTION:Vapor/Water ---1� ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> �rj� P ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC I] OTHER <br /> 21�SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL <br /> _0 SOIL BORING TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> EI�PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION(',All 5 O )❑HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: ❑OTHER: APPROX.BORING DEPTH_ r <br /> S ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> :OMMENTS: re <br /> CONDUCTOR CASING 0 No 0 Yes:Casing Dia: <br /> d Casing Depth: goring Dia: <br /> - <br /> 7v� <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREE ENTS OR ENCROACHMENT PERMITS <br /> )ESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD CHECK ALL rHAr APPLn <br /> #OF WELLS)TO BE DESTROYED <br /> YELL IDs: ❑ OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> :ROUTS. El PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> REMIE TYPE TO BE USED:E]AUGERS ❑HOSE ❑ PIPE ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> :OMMENTS El MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 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 all plicablsCalifornia Laws. <br /> igned <br /> Title/Company 7�, / <br /> riot Name ��S � '�-L GC�rIh /Pc <br /> Date <br /> rDr��EPARTMENT USE ONLY <br /> ITE MAP IN UNIT IV FILE SITE ADDRESS ��cf l?/e /�(, Ar " 1vL3EQ NocT' <br />/ORK PLAN DATED e E Z•O{Z <br /> PPLICATION ACCEPTED BY <br /> ROUT INSPECTION BY DATE ISSJ`� <br /> ESTRUCTION INSPECTION BY <br /> FINAL INSPECTION BY E 77„� <br /> �I '/ DATE 1—�- <br /> OMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC It <br /> of CODES FEE INFO AMT REMITTED CHECK# SERVICE RO# <br /> RECV'D BY DATE INVOICE <br /> REQUEST PR# <br /> 6 $125x 1 ZOZIy ifuct 2 Z f4 /3 SR# 3 <br /> 3)5- RO# <br /> (3500) <br /> PR# <br /> 57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT (2900) <br /> ENCROACHMENT <br />