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M xgPAt SAN JOAQUIN COUNTY C1 <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> :.4!a �•• C 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION_, <br /> Ui'( <br /> 1po�. Telephone:(209)468.3147 Fax:(209)466-3433 Web:www.slaov.orale' CNL 'fy <br /> .C' z.� i_ <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIO.N7,N 0 9 ZU14 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appllca0on Is hereby made to San Joaquin County for a penult to construct and/or Install the work desedbed. This application Is graQq'I(i;rp(r1(t<IGilt ivlth'Se�i'`�rl-` <br /> Joaquin County Development Tithe.Chapter 9.1115.3,and the Standards of the San Joaquin County Environmental Health Deportmen�.Fr1!,o;I-3 VIICLI <br /> -1 <br /> 2s/� 226, 2Z9r LS/ <br /> Site Location 290 Ok aSlyer:(- Crass Street �O.fk �1?rLv..e_ City/Slate �l _�yg Y <br /> � Zip 46'33} APN2r9-�34zq <br /> Property �� <br /> Owner Timaf'�t.i I`a/Brr�lAa- Address 2210 Qak- 3+ep. h City/Slate °so' Iree c,1 ZipgS33�Phone 209-6QZ <br /> C-57Contractor Caeeade a^ l.)re Address /7o 5. Z$ S>'Y2¢F City/Slate t ~Ltd P O Phone51Q-zol-0p9If <br /> ConaultanVSub Cntr�r"� Address?1 Clty/Statel..94 rLlc -^ Phona&I- T<-1-29ta✓0 <br /> Billable Party- %k�1�Address City/Slate �g-Zip 4W'f31- Phone 209 &D3.-- 390! <br /> '' GIS Coordinates:X n r Y 1 ' 44'r <br /> ?7 . -)760 - /2r rkfee, <br /> CONSTRUCTION WORK TO BEERFORMED: <br /> NEW WEI.LIBORINO(CPT, RO HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE d#OF WELL/BORING INSTALLATION TYPE CONSTRICTION SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2.-'It. 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING OW �-• <br /> _❑EXTRACTION:Vapor,water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL O PVC 0 OTHER -� <br /> _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL �TREMIE TYPE TO BE USED: O AUGERS ❑HOSE 0 PIPE <br /> "SOIL BORING rMfPUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yaa J.°.j No(MAXIMUM FREE FALL DEPTH IS 30 F'q 1 <br /> _OINJECTION Mentr3oe,oe.Moroi❑HAND AUGER GROUT SPECIFICATIONS9.5?P `p� g..j Ce_A. . f. ;7 <br /> _CI OTHER: 0 OTHER: APPROX BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> ''.",� `` CONDUCTOR CABIr�G�No❑Yoe:Cee1nB Dle: Caelna Daptlr. Bodne Ola:_ <br /> COMMENTS: 6i,q,�y� .-�t� 5g. =: 2%2%= <br /> \�.�o.l it`✓_� si i.1 S`R_�/ <br /> NOTE: OFFSITE WELLS S BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:rCHECKALL THATAPPM <br /> #OFWELL(S)TOBE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FTBELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:Q AUGERS ❑HOSE PIPE ❑MUSHROOM CAP AT(>_3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 6 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby certify that If Bove spared this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and aR'rpp b tll Ce:-!1 mle b . _ <br /> Signed �' � are� 7111e/Compeny sa.L..�r OAa. Ls /l��.._3a,,. l'a ,)e. On�11 <br /> Pdnl Name l\a_L� � Date 01/02/14 <br /> In �A, r1 DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 7y �TZEC—T/ iN 'g,re 14 <br /> WORK PLAN DATED J ANIAI{Ry ( I 20/q <br /> APPLICATION ACCEPTED BY _J, C/o 61":k-,I DATE ISSUED //Y-/Y AREA 1'r 4 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTEO CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 9,9o ( S126X (2 Lvv7Ee 1-94 SR# 4°8Uz <br /> RO# <br /> 3600 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER lu 0— C-67 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC nzd <br /> EHD 29-01 5109112 WELL PERMIT APP <br />