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COPY I <br /> peq�ll SAN JOAQUIN COUNTY 5 <br /> h. ,. ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stockton,CA 95202-3029 SITE MITIGATION <br /> Telephone:(209) 468-3454 Fax:(209)468-3433 Web:www.SiUov.orplend 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 I��yH,;;H r ry haul <br /> Application is hereby made to San Joaquin County fora permit to construct and/or install the work described. This application is made in compliace with San <br /> Joaquin County Development Title.Chapter 9-1115.3 and the Standards of the San Joaquin County Environmental Health Department r°t2a�Li rr.tt4 GLt <br /> SHGO,5f�LG ' IS,. ISr545 5qw 53W b9�F a zTw 'raft}� 1 <br /> Site Location Cross Street Rdn's w p p City , - M zjp962rjT APN i Dr 3C)r,3 lcv r3e 3a <br /> Property��" �KScc7ivrFe,Address �J}Cj} `V}4,rPsc%1vF U,G City SyeGtt 74..i Zip�S% t Pholie t7 3'r5-)-4f I <br /> Owner >-Ryr+E. 1)C45 AvD TL Cil Ll <br /> C-57Contractor C�2E(yt�Dgsu sw:� Addressg1 JC-S Nowr "'I city 144RTS>,je;y Lic LIUS&'G Phone (9Zi)313-Jd`OD <br /> Consultant[Sub Cntr C-&(r otj Address31C,OC�u;.D Vpu.E D^.a'L -'> C1tyhk1VIo GftL A Lic Phone C9(L�Ej L-411i: <br /> Billable Party Ggbr. / Address3110h7tksphone_(N)G�Fjl'kll.`. <br /> GIS Coordinates:X 1U220 y --f 21 31� <br /> ' CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GEOPROBE,HYOROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> 0 WELL IDs <br /> 0 OTHERIDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _i]MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE O MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: yl� <br /> ' _0 EXTRACTION::Vapor/Water 0 HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE O PIPE <br /> _0 SOIL BORING 0 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) y <br /> _O INJECTION(,a A,Swat Oronel0 HAND AUGER GROUT SPECIFICATIONS ,y <br /> ' _0 OTHER: 0 OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE {I` <br /> CONDUCTOR CASING 0 No Cl Yes:.Casing Pia: Casing Depth;_ Boring Cie. <br /> COMMENTS: <br /> ' NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:ICHECKALL THATAPPLY) y'1 <br /> #OF WELL(S)TO BE DESTROYED to OVER-BORE DIAMETER OF INCHES TO DEPTH OF PT ra <br /> - WOLLIDs: 1)6E A1O-ACPra5r.Tr ®PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE 1 <br /> ' GROUT SPECIFICATIONS N6*r C mj�,-r ❑EXPLOSIVES FROM TD FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:IN AUGERS 0 HOSE ®PIPE (a MUSHROOM CAP AT L?3 FT) FT BELOW SURFACE <br /> COMMENTS S'F ArnuA¢n -MgjL S SFk�.a..G+ paw . N.rrI rtiR n snt crrm.+ yC0' <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS T <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 /> Regulations,and a plic le Californla Laws. <br /> Signed \ _..�T— TillelCompany (" eoc6.J ow5vurnwtS uhA . ;zwP COrtiMt bsT <br /> Print Name Jd5ra C-"ofr Date 1 I?, <br /> [� DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS <br /> WORK PLAN DATED r, <br /> APPLICATION ACCEPTED BY ,-% wn KL- .,. DATE ,fiFd I't�,'r'�AREA=& <br /> Ico <br /> OROVT INSPECTION BY - ` E _ FINAL INSPECTION BY y yj, PATE21--(v <br /> DESTRUCTION INSPECTION BY .Yro f2'ttwavl DATE <br /> ' COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# LC1,1ECK <br /> FAC# SERVICE I'ft0#PE CODES FEEINFO AMT REMITRECV'D BY Lrl 1 INVOICE_ REQUEST PR;rS125xI _p __..Ro l- <br /> (2900 05212- <br /> C-57­11-- /-�%-- <br /> - V/C WAIVER �f _ C57 LETTER OI AUTHORIZATION TO SIGN PERA,iIT_ -____ENCROACI IMFNT DOC A/" <br />