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oPGe1ry • SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> a 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.ora/ehd UNIT IV <br /> �TrFOR <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 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 342 E,KaAISdl, Cross Street RL-4 City bh/ Zip 9� APN ��loC3oo'L <br /> Propertynn /I 9S'3 0 -y� .y. o <br /> Owner ,7�� r rFr �� Address City �A�H_ ��° Zip er 3 Phone <br /> C-57 Contractor f f�l i Address 1- 2L A I!C City f w 11 Lic�/a)/(O Phone <br /> Consultant/Sub Cntr Address City Lic Phone <br /> Billable Party Address City Zip 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 /> WELL IDS 9CIJI 7U W J A� <br /> OTHER IDS <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 3 Lip MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water O HAMMER/DRIVEN CASING THICKNESS sl ^ TYPE OF CASING: p STEEL 151 PVC [I OTHER <br /> _O SOIL VAPOR PROBE MUD ROTARY DEPTH OF GROUT SEAL 'J ID Sw MIE TYPE TO BE USED: O AUGERS O HOSE tCTPIPE <br /> _O SOIL BORING PUSH POINT(GP/CPT) GROUTSEAL PUMPED: Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) X <br /> _O INJECTION(i.e.Ar Soame.0...)O HAND AUGER GROUT SPECIFICATIONS 91I - roNn-1»J <br /> —[]OTHER:_ O OTHER: APPROX.BORING DEPTH 70 BOLTED TRAFFIC BOX OR O STOVE PIPE <br /> CONDUCTOR CASINGµp'N0❑Yes:Casing Dia: Casing Depth: Boring Dia:_ <br /> COMMENTS: K <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> _#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <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 /> Regulations,and all ap !cable California Laws. <br /> Signed ��- Title/Company 4% 151 <br /> Print Name 6r%cyry kor6sr_ Date !a/l4//// <br /> D A TMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS <br /> Ko <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE I_ _-� JOEA <br /> GROUT INSPECTION BY FINAL INSPECTION BY cu.l1­1 DATE en <br /> DESTRUCTION INSPECTION ^^ CC DATE <br /> COMMENTS/CONDITIONS: !Y G OP .SLS 1-�'✓��1�7" � <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE <br /> $125, 7 / �/ �� � I 1tJ G <br /> a9.v3 3.2 -ZS- l981 �,� 7n 11 ('3050g) <br /> NbZ <br /> PR# <br /> $ 2900 SU <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />