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A, <br /> • SAN JOAQUIN COUNTY • F IL.E COPY <br /> a t� ENVIRONMENTAL HEALTH DEPARTMENT <br /> P LOP <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone:(209) 468-3454 Fax: 209 468-3433 Web:www.s' ov.or /ehd UNIT IV <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 Title,Chapter&11,15.3,and the Standards of the San Joaquin County En`virroonmental Health Department. o <br /> Site Location 555 go It <br /> Street ?ALG�+c Ave City 01+oy% Zip APN dQI^a��D O� <br /> Property 6r <br /> Owner MlnEt [j, Cpt�Address � 130 t City S OL �p Zi <br /> ` P. QI_Phone <br /> C•57 Contractor S 1 Address ��2n�m c C1K Q City C4D ic_'3t?110 phone <br /> Consultant/Sub Cnu AR<Qpls Addressaomi?O(a41 7*r/Cor City F'MPf�JViW Lic Phone 9jD-6Z2-q <br /> Billable Party ARC.Fi�`ic Address 90th t�nu�Qll ryr� FL f Ciry Q U�II,Z N t <br /> GIS Coordinates:X Y Zip.J'140?Phone .S lO &5 2- /$O <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> MW NEW WELLIBORING(CPT,GEOPROSE,HYDROPUNCH.HAND-AUGER,OTHER) <br /> p❑SOIL BORING IDs <br /> CpWELL IDs W pll sD 1 <br /> ❑OTHERIDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �1q MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE T/ <br /> _O EXTRACTION:Vapor/Water 13HAMMERIDRIVEN CASING THICKNESS OMULTITYPE OF CASIPLE CASINGS NG: 0 MULTL D(PVC I-LEVEL WELL CASING DIA: <br /> OTHER <br /> _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: UGER❑S ❑HOSE S°r PIPE <br /> _O SOIL BORING O PUSH POINT(GP/CPT) GROUT SEAL PUMPED:JQ Yes,❑, No(MAXIMUM FREE FALL DEPTH IS 3D/FT) II p 11 <br /> INJECTION fie ArSnarae Ozonal i]HAND AUGER GROUT SPECIFICATIONS_ugYl•I"O1fl61d " CQd"0'r%.' S�LU ?".A1YFL' <br /> OTHER: OTHER: SOf1I V APPROX BORING DEPTH /5: O IHD rg BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> 1 CONDUCTOR CASING No❑Yes:Casin(g(��Dia: - Casing Depth:_ Boring Dia: <br /> COMMENTS: I-Wo UagILV - 20 k+ se CQQt\ \Qi1G?�� Cneowf SQ41. 1•Y-{ 46oVf $GfBCTt'I'o S <br /> NOTE. OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS4� <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD,(CHECK ALL THAT APPLY) <br /> _#OF WELLS)TO BE DESTROYED <br /> WELL IDs: <br /> LJ DIAMETER OF INCHES TO DEPTH OF GROUT SPECIFICATIONS ElPRESSURE GROUT To DEPTH OF t <br /> TREMIE TYPE TO BE USED.❑AUGERS ❑HOSE ❑PIPE ❑ FT BELOW SURFACE <br /> EXPLOSIVES FROM To FT BELOW SURFACE <br /> COMMENTS ❑ MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS- <br /> -I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules d <br /> Repul#NofTas, nd I app' able Cal' omi S. <br /> Signed Title/Company A IZCl9_ p l S �ISPh O IN <br /> Print Name <br /> pp DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS_ T�Cft r�(C d- &-,u 1{01-7" /7RI( G <br /> WORK PLAN DATED / 2 <br /> APPLICATION ACCEPTED BY �� /6y <br /> GROUT INSPECTION BY Cql <br /> FINAL INSPECTION BY <br /> /U•1L-[Z <br /> DESTRUCTION INSPECTION BY DATE DATE <br /> COMME NTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO O <br /> REQUEST PRO INVOICE <br /> 2-Go $125x 2 2 - 04c S 25 �yurUrb4 5' ,-12 SR# 8 <br /> 2903 375 T�5 RO# <br /> Z 3500 <br /> PRO <br /> G57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT !/ ENCROACHMENT DOC <br />