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• • FELE <br /> ,qP4 ,•.. SAN JOAQUIN COUNTY <br /> eyA—, ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> '�° r• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone:(209)468-3147 Fax:(209) 468-3433 Web:www.slaov.orn/ehd UNIT IV__ <br /> koP WELL & BORING PERMIT APPLICATION ".�, . y -�.. E,r) <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �p'[T <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&1115.3,and the Standards of the Sen Joaquin County Environmental Health DepanmelR4VIRU M N'I AL t/-LT <br /> 2i/r Z24 221, LSI P 114Pf, ;;A__2 <br /> Site Locadontl 290 Qak Slrtt(- Cross Street 1�a,t{� Aete.•% City/Stale l�_,.4g�Zipgs33_1- APN'Zl - 3 Zt ?.St +ZAI <br /> Property � / <br /> Owner Time UJ� A <br /> 4�PJ AI Address 22(o mak .5f'rPeF- CltylState�ay ZlpgS33iL Phone209j(o02- p/ <br /> C-57 Contractor C4ce a � - Address 12o 5. ZCity/State n Llcy38/10 Phone5,(O-2A}'009 <br /> Consultant/Sub Cntr6a � .Address 313511Fo:rc toUi AD city/stateLAJ�LIc —' Phone&L: ��I-2Ttao <br /> Blllahle Party^iIQ Address L'Lt. 6gtc S-Lreet City/State Zip QS'f37- Phone Log-(eOZ- XCjOI <br /> GIS Ccordlno.es:X 01 I Y f 21p1;� - ',•4?), <br /> � ?.7 O -f2,1 2197 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,(E?ROB HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDS <br /> ❑WELL IDS <br /> ❑OTHER IDs <br /> TYPE E#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z"k. ❑MULTIPLE CASINGS CI MULTI-LEVEL WELL CASING DIA <br /> _,7 EXTRACTION:Wpod Water ❑HAMMERioRivEN CASING THICKNESS I TYPE OF CASING: CI. STEEL G PVC ❑ OTHER <br /> _[3 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS [I HOSE ❑PIPE <br /> j� k <br /> SOIL BORING MPUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes— ;AN o(MAXI��MI/UM FREE FALL DEPTH IS 30 F17 <br /> _O INJECTION rte Ar S,,, Drone)❑HAND AUGER GROUT SPECIFICATIONS 9"9s I�?r�a-tln.w� W -•F 'g' fwe - <br /> _0 OTHER: ❑OTHER: APPROX BORING DEPTH ❑BOLTED TRAFFIC BOX OR D STOVEPIPE <br /> t <br /> 521- CONU0T1OR CA5X�Nooa YraiC_em nB fC �� Ca$n �n:� BonnO Dle: <br /> —COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THATAPPLY) <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 T BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE El PIPE C3 MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby certify that Faye gg oparad this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and aI.&,p r% z:!lbbbmmmis // <br /> Signed �� �� TItle/Company �Pya.X opefiA.�»n5 Mo.,i jh�' <br /> 3 l'��J�On <br /> Print Name IS��_F(T Date 01/02/14 <br /> n DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS ala oAr SrRC-ET Gam'119V 7Z'C!R <br /> WORK PLAN DATED -��NUI��"1 �il ZU/� � Aeek-'7W ti �. -�-�' <br /> APPLICATION ACCEPTED BY DATE IS9r <br /> GROUT INSPECTION BY FINAL INSPECTION BY vo TE <br /> DESTRUCTION INSPECTION BY DATE r' <br /> COMMENTS" Not DNS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> pp �7 �y �/ REQUEST PR# <br /> $125x :7o7 Coul?E7 - (-/ I SR# 'TO <br /> 7403 a o0 <br /> PR# <br /> 2900 <br /> C-57 ✓ WC ✓ WAIVER V1- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC �I <br /> EMD 29-01 5/09/12 WELL PERMIT APP <br />