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• a " <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 LOP <br /> �''<•iFo ;;`t Telephone:(209)466-3454 Fax. (209)466-3433 Web:www.s c ora/ hd SITE MITIGATION <br /> `� UN�Iy <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 County Development(T(�iffe,Chapter 9-1115.3,and the Standards of <br /> 11ftt the San Joaquin County Environmental Health Department. <br /> Slte Locatlon6� 66 1P&CAtc Ave Cross Street �7Qt11amin ti ol'I" <br /> Ownperty C11- o� S'�bG Address Qty 5}Pro �—Zip APN 081:1 <br /> C-57 Contractor Cp$((L ebo"M,L, City Zip Phone_— <br /> �n ��� Address 3(032 OMQC, Ci,r <br /> ConsultanVSub Cntr ytQCQQL$ Address 2DOt7�oll - rrflr City�trnc�DCD1600"Lic 93E�rlD Phoma 91�_ o , I/ <br /> Billable Party AIZCAO% S neon city I mQt�vl G����o <br /> Address - S a ,e eN V I I6 e+c=Phone <br /> GIS Coordinates:X city ZIP Phone <br /> Y L vlkl1�LOcgFI61N1r on Re <br /> CONSTRUCTION WORK TO BE PERFORMED: y4rtltn No�#• <br /> LSd NEW W OIL BORING <br /> (CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> WELL IDs „ <br /> OTHER IDa <br /> 'XTYPE 8#OF WELLIBORING INSTAL_ LA�TYPE CONSTRUCTION SPECIFICATIONS <br /> 7"MONITORING ❑HOLLOW STEM /I <br /> _❑EXTRACTION:Vapor/Water DIA.OF BOREHOLE(_ O MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING CIA <br /> ,- <br /> -0 <br /> ❑MUDRO ROTARY <br /> (_II <br /> SYN LAO <br /> _O SOIL VAPOR PROBE ❑MUD ROTARY TYPE OF CASING: 0 STEEL �pVC � OTHER <br /> —O SOIL BORING DEPTH OF GROUT SEAL' TREMIE TYPE TO BE USED: ❑AUGERS E <br /> Q PUSH POINT(GPI CPT) GROUT SEAL PUMPED: yes ❑HOSE It)PIPE <br /> _0 INJECTION Its Nr Cn- O• - )❑HAND AUGER /�' ❑No(MAXIM1UM FREE FALL DEPTH IS 30 FT) <br /> _O OTHER: GROUT SPECIFICATIONS 5_a Q en-t—y- Q Cpm21n-I' <br /> OTHER: SBhIG APPROX.BORING DEPTH 75_/ p I 13D/ �p <br /> �1 1 ----�� r BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: .( wQI1 CONDUCTOR CASING No❑Yes:Casing Me: Casing Depth;_ <br /> - ?Osr+ 4�caQtl�cha t`e -E•se I .� �4+ G, goring Da__ ' <br /> NOTE OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT RMITS <br /> DESTRUCTION WORK TO BE PERFORMED: <br /> #0. WELL(S)TO BE DESTROYED RESTRICTIOMETHOD'(CHI A_APPLYI <br /> WELL IDS: ❑OVER---vORDIAMETER OF <br /> GROUTS ❑PRESSURE GROUT TO PECIFICATIONS DEPrH OF INCHES TO DEPTH OF FT <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑EXPLOSIVES FROM FT BELOW SURFACE <br /> COMMENTS ❑PIPE El MUSHROOM CAP AT L3 FT)_TO FT BELOW SURFACE <br /> —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 /> Regula0 d aI app cable Califomla L . <br /> Signed nal � ,( <br /> Print Name tt 6� c-� r TitlelCompany F1�Cl�D(S - c�p�Iov, Geol lws <br /> Date lO- a3- 2D12 <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS DEPARTMENT USE ONLY <br /> WORK PLAN pg7Ep <br /> APPLICATION ACCEPTED BY <br /> GROUT INSPECTION By DATE ISSUED_ to— z AREA <br /> DESTRUCTION INSPECTION BY FINAL INSPECTION BY <br /> COMMENTS/CONDITIONS: <br /> DATE DATE <br /> ACCOUNTING ONLY: AID# <br /> PE CODESFEE INFO AMT REMITTED CHECK# FAC# <br /> RECV'D BY DATE SERVICE RO# <br /> $125 x z 1455_34REQUEST PR#. INVOICE <br /> 2 O� 37 /b-Z5=1L SR# & Olt-1 <br /> RO# <br /> 3SOD <br /> C-571PR# <br /> WAIVERC57 LETTER OF AUTHORIZATION TO SIGN PERMIT /i ENCROACHMENT DOC_ <br />