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opo"I SAN JOAQUIN COUNTY FILE COPY <br /> y �r ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone:(209) 468-3454 Fax:(209)468-3433 Web:www.sioov.oro/ehd UNIT IV <br /> ?FOP <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 andlor install the work described. This application is made in compliance With San <br /> Joaquin County Development Title,Chapter En and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 333 W. Sen�dalin liolf Cross Street Glnn�nn city 5+0&+0ri zip APN 09 ado-a s <br /> Property ,} (• �t 1 <br /> Owner Ct yp ec or% AddressCiry /` Zip Phone <br /> C-57 Contractor CAB ca&br'%Ik(h Address 3(x32 Omer, CIOCIe1 CCityp FdnAo C0TjciULIC 9VPII0 Phone9/(0-639--5'0II <br /> COnsultanVSub Cntr ARCAMS Address zyo Powekl5t Y*Flooc`city,Ehrefybille Uc Phone 510-07A-15L1'1 <br /> Billable Party AJRam-, Address SAmI? City Zip 91j(Dog Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER) <br /> ❑SOIL BORING IDs <br /> �VVELLIDs Well A3 rwnd 13 <br /> OTHERIDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 2-IX MONITORING ❑HOLLOW STEM DIA OF BOREHOLE (p " ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA- <br /> -0 <br /> IA-0 EXTRACTION:Vapor?Water ❑HAMMER?DRIVEN CASING THICKNESS G CN H0 TYPE OF CASING: ❑STEEL Cill PVC ❑ OTHER <br /> —0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE IX PIPE <br /> —❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:IPJ Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ❑INJECTION(i.e.Air Soama.Ozonat❑HAND AUGER GROUT SPECIFICATIONS 561u QeiltOhpye - eQP]Qsl� <br /> —0 OTHER: IP OTHER:_S OYTtG APPROX.BORING DEPTH rJ S 4t and 131); W BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING�No❑Yes:Casing Dia: Caving Depth:_ Boring Dia:_ <br /> COMMENTS:TVJo Wells - .2 �t Gaeen.s - Gvoui- Saal ;� Aft o"v sceeer% su.eZ:r <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD,(CHECKALL THAT APPLY) <br /> _#OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OFT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT 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 /> RegulSigned tlopsrapd qii applicablaQCaq)omiaaws. /(p n <br /> Signed ((44.�KC) u1X19�.1�� �rrrll44..C� �� Title/Company �r f��+n Ms SQ!\r1DC 17 QO10�15� <br /> PrintName izbeek O'L a sk eU Date jig - ;?S- z-61LDEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS P1994 I IC vLGAJ ffO4;)- <br /> WORK PLAN DATED '-0( 2 <br /> APPLICATION ACCEPTED BY J• cJ C)[aKH d'f DATE ISSUED 10 -zrl�I Z AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COM MENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> REQUEST PRO <br /> $125, 2- qS 3_ Cauni, k /bz/-/ REQ I <br /> RO# <br /> 3500 <br /> PRO <br /> 2900 <br /> C-57�L WC ,_WAIVER A'k�= C57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC <br />