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- --- ------- <br /> 0 r V tM <br /> SAN JOAQUIN COUNTY R7 <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATI( <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sicimo alehd <br /> '6 <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIAT FN <br /> NON-REFUNDABLE PERMIT EXPIRES I 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 Dev,' , ,M Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location \/,W�tGy.& ,S14Q;y("t�'OV Street E, Z;� � A City/State LA4W L&p I 990/06 41 <br /> -e:j� CrossI I _JS 30 APN <br /> Property V Address City/State LAJL,,� �C?lp_12jLZ�_Phone(I 09)4y- <br /> Owner P pl_\�, S, <br /> C-57 Contractor (�srg!)gl J)r,J��t� Address 95'6 d City/State &AjA-_, CAUG qj.<7A!� Phone(.11.2:5-) 313- <br /> Consultant/Sub Cntr Address City/State Lic_Phone <br /> Billable Party Address City/State Zip Phone <br /> GISCoordinates:X—Y_ <br /> CONSTRUCTION WORKTOBE PERFORMED: <br /> F1 NEW WELL1130RING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> El SOIL BORING IDS <br /> E]WELLID <br /> 0 OTHER IDS <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �50 MONITORING t&HOLLOWSTEM (6) DIA.OF iD" DMULTIPLE CASINGS[3 MULTI-LEVEL WELL CASING DIA:— <br /> —[I EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS " (A 0 TYPE OF CASING; [I STEEL K PVC 0 OTHER— <br /> _[I SOIL VAPOR PROBE ,MUD ROTARY (,I-) DEPTH OF GROUT SEAL.5'.- 13S REMIE TYPE TO BE USED: 0 AUGERS El HOSE X PIPE <br /> El SOIL BORING I-]PUSH POINT(GP/CPT) GROUT SEAL PUMPED:[b Yea [I N.(rXIMUrE.EFALL DEPTH IS 30 FT) <br /> —0 INJECTION(I a NrSparq,.Oz,�,)0 HAND AUGER —GROUT SPECIFICATIONS— <br /> _[I OTHER:— 0 OTHER: APPROX.BORING DEPTH 2� [I BOLTED TRAFFIC BOX OR U STOVE PIPE <br /> kjX Tf_0 ON'DUC��ASItV 0 No 0 Yes: Casing D7�=_ <br /> COMMENTS:- OAQ� a <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD,(CHECK ALL THAT APPLY1 <br /> #OF WELL(S)TO BE DESTROYED El OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDS: El PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS0 EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:El AUGERS 0 HOSE El PIPE L_j MUSHROOM CAP AT L>3 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 /> Regulations,andalLais able C ornia laws. <br /> 1p�le �SrOln(",4 <br /> Signed TitlelCompany 1.ff <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS eq- !50 _��T-H 9,,�,14> 2012 <br /> WORK PLAN DATED FKIXIIRM <br /> k <br /> APPLICATION ACCEPTED BYa N DATEISSUED 'l2- Z. PERWDATE /0 WRV <br /> �INALINS�PECTIO� B <br /> GROUT INSPECTION BY <br /> ESTRUCTION INSPECTION BY DATE <br /> OMMENTS <br /> OLIN G ONLY: Ain 9 <br /> S RVICE RC <br /> v\O <br /> PE CODES FEE INFO AMT REMITTED CML-CK;F I REQUEST FKF I <br /> INVOICE <br /> C) 5 $125 X SR# <br /> I/. I Z_ RO# <br /> (Dcq� (oq2 -- (3500) <br /> P # <br /> //375- 02-0071 (2R900) <br /> WC 1,/ WAIVER A/14 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT � ENCROACHMENT DOC77—V <br /> WELL PERMIT APP <br /> EHD 29-01 5109112 <br />