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� REG D <br /> ENVIRONMENTAL HEALTH DEPARTMENT°P4uIN ° SAN JOAQUIN COUNTY ri <br /> CO NDVLOP @ P1 <br /> a' NT <br /> Q � <br /> IF <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 EWRONItII�f 1 {WN <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:WWW.siaov.orq/�RMI?1SE <br /> �/FOR <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 RCXD <br /> Joaquin County Iply p�nent Title, Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department.-rY���J I o81- Iti Q-lo <br /> Site Location Tr6p tnco1rt lZ� Cross Street ZhslPwbocl AUS City .S4'c 'n Zip APN <br /> Property ,} SI 1 1 \ II 11� <br /> Owner Ct rdv To dc1t'on Address S1c�evo¢1`Z P4S8eYlBnf City Zip Phone 9p r/ <br /> C-57Contractor CQSC(CQeDr`lI ''w� Address 31932 nMCC. � City . -.nc D D Lic 38110 Phone`l/1L-/a Jd'�7I[/II <br /> ��- <br /> ConsultanVSubCntr /1RC4W\ , Address 2C)790 F,,OQII S+ 7'17-Icity Err QCyVllle Lic Phone <br /> Billable Party ACS CAD15 Address Sam City Zip "ILUk Phone <br /> GIS Coordinates:X y <br /> CONSTRUCTION WORK TO BE PERFORMED' <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑ SOIL BORING IDs <br /> f�.WELL IDs_ /a I Pi vYd C3 <br /> t]OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORINGrI <br /> ❑HOLLOW STEM DIA.OF BOREHOLE � [I MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA' <br /> _❑EXTRACTION:Vapor/Water Ej HAMMER/DRIVEN CASING THICKNESS Sc4l '10 TYPE OF CASING: ❑STEEL V PVC ❑ OTHER <br /> —0 SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes E]No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —O INJECTION(iV.e ASoaroe Ozonet❑HAND AUGER GROUT SPECIFICATIONS .5%0 �Qtl�l.nll E�— &K-Out- <br /> _❑OTHER: to OTHER:SOMI c- APPROX.BORING DEPTH 25' n.l I.;0' 91BOLTED TRAFFIC BOX OR [:]STOVEPIPE <br /> LL-'c <br /> CO1 NDUCTOR CASING IW No❑Yes:Casing Dia: 77'' Casing Depth:_ Boring Dia: <br /> COMMENTS: 1lA'r7 IA)c.1I1 — r�O SCru('C15 C^Q'� t7 e¢I 2 r \ Ova SCcc.EYl :6-s lfr co <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK 70 BE PERFORMED: DESTRUCTION METHOD'(CHECK ALL THAT APPLY) <br /> _#OF WELL TO BE DESTROYED ❑ OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑ PRESSURE GROUT TO DEPTH of FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To Fr BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑ PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS <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 /> Regula!t'0 s,/,an�all�pplicable California Laws. v <br /> Signed �Sa.X.t.tX (7d./F,al. I —Title/Company � � aL�IS / SknioC (~r�;�glS <br /> Print Name _ RV�et.+ (7t1.bQ511ciy - Date ld-31 - I � <br /> p DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS Y _I I e �- r,J&N 1�-4 - -5?DfKM1,/ 5"iLVot� �I,GA, <br /> WORK PLAN DATED 19U6-tt$7- 2 3 201 2 oc <br /> APPLICATION ACCEPTED BY *Qg G t DATE ISSUED Il-7-1 2'- AREA 16 t <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY - DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> $125X1 oyS837 ^mclvt /(-(.pZ_ SR# 66103 <br /> RO# <br /> (3500) <br /> PR# <br /> C-57 WC —WAVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ( ENCROACHMENT DOC <br />