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• * FILE COPY <br /> ,a�R :•,� SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> cad'° 1868 Hazelton AStockton, CSITE MITIGATION, <br /> !Q! T NIPS <br /> azeonvenue, A 95205-6232 <br /> p Telephone:(269)468-3147 Fax:(269)466-3433 Web:www.sigov.orglehd <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION j AN 09 2014 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a peril to construct and/or Install the Work described. This application Is made I {3EALTFk <br /> PP �Lt �ia�I: 1�FY Sea <br /> Joaquin County Development TIUe,Chapter&1115.3,and the Standards of the San Joaquin County Environmental Health Department. P RtvriT/SE ICES <br /> 2s// 2xr. ZZ7, LSI 2-1390-/$ <br /> Site Locatloni 24•o c7at s(yeel- cross street i?o.rk Anteowa- City/State I��ZIp4S33^1 APN2/4' 390-22+7j/+ZL( <br /> Property <br /> Owner '7 11D/ iri 119/49 AAa. Address 2Zto .v're Clty/State o . e Lp 9s 337- Phone Z09^(a02^.�90/ <br /> C-57 Contractor Cac AA Address 120 S. ZSCS' Sl-re0- City/State R'& Llc93V(L Phone 51A-20}^008 <br /> Consuhant(Sub CnV .Address 33< u. eIA Qd db City/State .L. Llc Phone Fal- 1L1161-L!!QO <br /> Billable Party-f-M a Address ?.?-&. Oala S{^ree_ City/Stale hk�,�em zip wan- Phone L ft_-&Q - 39o1 <br /> GIS Coordlnatea:X }�}�-'�,(r' �Y 1 '- 47" <br /> 3�- G -1]/. 3,/ Z <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> je NEW WFLUBORING(CPT,jZ2LROBPHYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA OF BOREHOLE Z IF,- 0 MULTIPLE CASINGS 0 MULTILEVEL WELL CASING DIA � <br /> _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS ITYPE OF CASING: D STEEL 0 PVC ❑ OTHER — <br /> —0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS ❑HOSE 0 PIPE <br /> SOIL BORING 9PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yea �No(MAXLMIUM FR€E FALL DEPTH IS 00 FT) <br /> _O INJECTION ne A,S,,Omer 0 HAND AUGER GROUT SPECIFICATIONS 9�i ►mss Hn . I W ;' <br /> _0 OTHER: ❑OTHER: APPROX.BORING DEPTH .3d•Rea_ ' 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> t1 CONDUCTOR CAST G&,0 Yee:Ceeing Dle: Ceeln9 Depth: Borne Die: <br /> COMMENTS:. 1n..t.ee c�sa•.t �L� <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:0 ANGERS 0 HOSE ❑PIPE ❑MUSHROOM CAP AT Q3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I havp repared this application and that the work will be done In accordance with San Joaquin County Ordinance,Put=and <br /> Regulations,and Sow "bl Nf rnla rhxre. cc�� 1,^l�n. // <br /> Signed TIlle/Company ")� M.D✓ Oae.ra.l arL5 /1Rw_30✓ %4, ®/Tlh <br /> Print Name Date 01/02/14 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT PJ FILE SITE ADDRESS ?C= 6,- �77C.C�T- nn /V.' -�Al <br /> J <br /> WORK PLAN DATED ' IVU 6 R 2& ( <br /> APPLICATION ACCEPTED BY 1. �O I'iKu.vF DATE IS <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY _ - l DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO N INVOICE <br /> REOUEST PR# <br /> $125X i 12� SR# SRa �y <br /> RO# <br /> 3500 <br /> PR# <br /> z90D <br /> C-57 ✓ WC ✓ WAIVER DJ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC <br /> EHD 29-01 5/09112 WELL PERMI APP <br />