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�� J �' �►-�, <br /> I 4(aul • SAN JOAQUIN COUNTY SC <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> c SITE_MITI.G(1 )ON <br /> 1888 Hazelton Avenue, Stockton, CA 95205-6232 f r <br /> Tele hone: 209 468-3147 Fax: 209 468-3433 Web:www.s ov.or le d f 4►��11V <br /> P ( 1 ( 1 la o null <br /> WELL & BORING PERMIT APPLICATION Ip�I ® � Za►!t <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION' <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED nn p��t� �+ <br /> Application Is hereby made to Sen Joaquin County for a permll to construct and/or Install the work described. This application Is�iil3d✓!(n'domgltpTl�@ `r+yam nLT`I <br /> Joaquin County Development Title,Chapter&1115.3,and the Standards of the San Joaquin County Environmental Health DepertrnefiPlwRlJl 1/97tliUl4 <br /> 2s.W, 226,229,Lffl :] 21 -3010-/$ <br /> Site Location-4 2�o Oak Sfree(- Cross Sheet VOW {�V4..�v-e- City/State M�l�Zlpgs33-1- APN2w-i9n -Lzr73(•F z4 <br /> Property �A <br /> Owner 17mnf� I/a /PRurbl of Address ZZ(o 0,2 h 5M2eE CltylState Agh� �gLp SL-,S 33ll- Phone 297-:. of <br /> C-57Contrectorcacee a Q^r City/State Pi&mw Uc43R/10 Phone'5(r)-WV- <br /> AD <br /> i ConaultenVSub CnV .Address' CltylSIaleLQT10 LIC Phonaf301� �4•I-28atD <br /> Billable PartY�1 Address Clty/Stele Zip oD5`71} Phone z.09-/eOz- 3901 <br /> GIS Coordinates:X 3V'ja'V&Y 11;5 1.49 rr <br /> 1? '2f G -l2t"),I).l <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,V2EROBPHYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDS <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING O HOLLOW STEM DIA.OF BOREHOLE 2 r a. ❑MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> _O EXTRACTION:Vaporl Water ❑HAMMER/DRNEN CASING THICKNESS TYPE OF CASING: 0STEEL 0PVC O OTHER �- <br /> _O SOIL VAPOR PROBE O MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS []HOSE O PIPE <br /> "SOIL BORING PfPUSH POINT(GPI CPT) GROUT SEAL PUMPED:O Yea XNo(MAXI.MIUM FREE FALL DEPTH 11.11 FN <br /> _D INJECTION 11,Mrs,=o,,I❑HAND AUGER GROUT SPECIFICATIONSQsg �di'1 ---� C�r.o��' �/ <br /> _O OTHER: ❑OTHER: APPROX.BORING DEPTH Rftk O BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> t CON1D-UCTOR CAST ,,d No O Yee:Ceeing Dla: CerinO Depth: Boring Die:_ <br /> COMMENTS: t_a.-,�,p_I�t4��s �.,�l� SOC S&�: `pit c�lPs_p,aic—fs�Ie� <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD'(CHECK ALL THATAPPLn <br /> --#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF_INCHES TO DEPTH OF Fr <br /> WELL IOs: ❑PRESSURE GROUT TO DEPTH OF FTBELOWSURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FTBELOWSURFACE <br /> TREMIE TYPE TO BE USED:0 AUGERS 0 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 1 erv0 prepared this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Reguletiona,and el;-,p ?,!t19grrala,lawwe. C��+�� A <br /> -- <br /> Signed 1 - /% TIIIe/Company r-19.'dd Au opeM 5; Mo..&j.e <br /> Pdnt Name Ka 4p6 A& l� �.� Date 01/02/14 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 2 70 !Q AK eA7 <br /> WORK PIAN DATED _J/I,Nk/i Rq (I 20/U <br /> APPLICATION ACCEPTED BY J- HO r.K< tVr�_ _ DATEISSUED I-/V- /°I AREAICQ�! <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE .� <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> RVICE <br /> PE CODES FEE INFO AMT REMITTED CHECK RECV'D BY DATE SERO# INVOICE <br /> REDDEST It # <br /> a�o5 <br /> $125x I l2 701 Cvav1Z-1� 94y SR# 4RocY,.5i `/l <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 WC ✓ WAIVER P1/6- C-67 LETTER OF AUTHORIZATION TO SIGN PERMIT _4,--' ENCROACHMENT DO <br /> EHD 20.01 5109112 WELL PERMIT APP <br />