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p�4S!i!y. FAL E <br /> Copy SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> COP <br /> 1868 East Hazelton Avenue, Stockton, CA 9520 L <br /> c•�• •R Te%phone:(209)468-3454 Fax.-(209)468-3433 Web: 5-6232 SITE MITIGgTION <br /> WELL & BORING PERMIT APPLICATION�r9� UNI_ <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND <br /> Application is hereby made to San JoagNQN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM D REMEDIATION <br /> Joaquin County Development title,Chapter County <br /> and the Standards Of San Joaquin County ATE ISSUED <br /> ty for a perms} t ndard oonstrlc}and/or install The work ty EnOron This application is made in compliance vn <br /> Site Location FQ Q$iC fd vQ (;ron'FcCB t: 1' I ty Environme is Health on is made i <br /> Cross Street W FA'I aQYt\A Mlh N 1 im N San <br /> Property D la s1 ,I <br /> Owner C. — J (y 1p�JsOn zip APN Qg( ,7= <br /> C•s7 Contractor c t'i l�'q city <br /> Consultanusub Cntr A�'��� Address�9-�.9.Y 3(y O pm ec�cciry, n (fir zip Phone�— <br /> % Ul$ AddressQpOO�o�p��C} Fjlb IIO Phone <br /> Billable Party At?rws ---- _ City a •� - <br /> F/r <br /> GIS Coordinates:X—Y Address Lic Phone Sl0_ ys� <br /> City <br /> Zlp� Phone_ <br /> CONSTRUCTION WORK_7_^_ <br /> BE PE FORMED: <br /> NEW WELUBORING(CPT,GEOPROBE,HYD <br /> SOIL BORING IDs L[j ROPUNCH,HAND-AUGER,OTHER) <br /> WELL IDS <br /> ❑OTHER IDs <br /> TYPE 8 a OF_ WE—NG INSTALLATI N TVVF <br /> —0 MONITORING �C4NSTRUCTIDN PECIFICATION <br /> _0 EXTRACTION:Vapor/Water 13 HOLLOW STEM DIA.OF BOREHOLE 6 in <br /> 0 HAMMER/DRIVEN -'— 0 MULTIPLE CASINGS�MULTI-LEVEL WELL CASING DIA:_ <br /> _O SOIL VAPOR PROBE CASING THICKNESS <br /> MUD ROTARY DEPTH OF GROUT SEAL (LAO' TYPEOFCASING: STEEL pVC <br /> SOIL BORING 0 PUSH POINT(GP/CPT TREMIE iIPE TO BE USED: 0 AUGERS11 OTHER <br /> —0 INJECTION pe A c _.., „_ ) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 HOSE PIPE <br /> _O OTHER: ❑HAND AUGER GROUT SPECIFICATIONS 13 e n Or,t ,L �/��7nJ 1 ` J <br /> ���OTHER: OI1IC t �e 'Ce.mz f J / rO(ticl erc� ¢ F <br /> APPROX BORING DEPTH <br /> COMMENTS; QhQ, S' �1 r ONDUCTOR cpglryG —�0 BOLTED TRAFFIC BOX C ❑STOVE PIPE <br /> Dh pp b 4�an _ J1_�Ib ❑NoO ies;CasingDla: <br /> n\ QL O 1 I M Casing Deplh Boring DI <br /> NOTE OFFSITE WELLS$BORINGS REQUIRE ACCESS AGREEMENTS ORE 1 11 I ; _ HMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED; nC f ERM.^.Ao�iOVi <br /> #oF WEu(s)r-BE DEsmQYEO <br /> WELL IDs: D TR TION METHOD/ <br /> K_A_I T <br /> GROUT SPECIFICATIONS U OVER-BORE uwMETER OF — 3`04�- <br /> TREMIE TYPE TO BE USED: AUGERS HOSE O PRESSURE GROUT To DEPTH OF INCHES TO DEPTH OF <br /> ❑EXPLOSIVES FROM FT <br /> COMMENTS ❑PIPE --_T� PT BELOW SURFACE <br /> ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> FT BELOW 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS SURFACE <br /> I hereby certify that I haus prepared this application end that the work will be done in accordance with San Joaquin County Regulations,and lapplicable Cilifomiay <br /> aws. <br /> Signed p my Ordlnan Relse and <br /> Print Name - 1 S Q TiOe/Company fl ZCA fl�S (Senipr (-i e�gy` <br /> DEPARTMENT USE ONLY <br /> ,p Date /p <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS a 1t /e pc <br /> WORK PIAN DATED t �� N601,T- /%2/U� <br /> U <br /> APPUCADONACCEPTEO eY 3 <br /> s. vb7t <br /> GROUT INSPECTION BY <br /> DATE ISSUED //'j_ //-�Z AREA / <br /> DESTRUCTION INSPECTION BY FINAL INSPECTION BY <br /> COMMENTS/CONDITIONS: <br /> DATE DATE <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO <br /> AMT REMITTED CHECK# <br /> �1(+l RECV'D BY DATE SERVICE RO N <br /> { i 0 $ 125, ,/ ?Z REQUEST PRAI INVOICE <br /> 7'�o3 3�S f J G / sR#5R� <br /> RO# <br /> 3500 <br /> c-s7 we P� SoG Z0 <br /> WAIVER-�� C57 LETTER OF AUTHORIZATION TO SIGN PERMIT 2900 <br /> ENCROACHMENT DOC <br />