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�► � � FILE copy <br /> ,qPA •., SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> eyA' 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone:(209)468-3147 Fax:(209) 465-3433 Web: ww.slaov.ora/ehd r m fit <br /> W _—[ <br /> WELL 8t BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATlojjJ,C\S <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a penult to construct and/or Install the Work described. This application Is rfra�P�'1(1?�0)rj(t(Il¢IOe`with Sen L <br /> Joaquin County Development TIOe,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Deparlirien§EFgrt(TI <br /> 2sy, 220, ZZy, Zvi3199 39'0—t8 <br /> Site Location-* 27o dkk: Sinal- Cross Streetiso r6 A1H?XItA.L City/State A4w Vw zlp'9n3'1- APN 219' � 4 Zl( <br /> Property ,A , - <br /> owner 17&-'p i,. 1/a/Wi Am- Address 2Z(o �o �. 31L"e.l- CitylSfafe y�Lp'RS33+ Phone 209-(apL-ffal <br /> C-57 Contractor a Q-,-//.l,e Address 120 5. ZS Sh'2a.1- City/State Kr&maJ LlcySP//0 Phone'S10-Zo}-008If <br /> ConsultentlSub Cntr �. Address CltylSfate(lAJ�IUr Llc Phoned- ', 41-2800 <br /> Billable Party r Address tZl. OQI` CltylStale Zip 'W't37- Phone Lo9 &DZ-- 3901 <br /> GIS Coordinates:X ` Y t 111" <br /> o . 121 1r G <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> Xr NEW WELUBORING(CPT,jZ2LROBPHYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE 8#OF WELLMORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA OF BOREHOLE 2 ra. 0 MULTIPLE CASINGS 0 MULTPLEVEL WELL CASING CIA: <br /> _❑EXTRACTION:Vapor/Water 0 HAMMEPIDRNEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> _0 SOIL VAPOR PROBE 0a.�rMUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> "SOIL BORING K PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes X No(MAXIMUM FREE.FALL DEPTH IS 30 FT) <br /> _O INJECTION 11,ArS ,,o,Ornn,n O RANO AUGER GROUT SPECIFICATIONS qJ'�s /7ra�-/L-�on cam".f. 19 &.4'�(-z <br /> _O OTHER: 0 OTHER: APPROX.BORING DEPTH 3®•FC2T 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASI GA No❑Yea:Casing Dle: Ceolnp Depth; Bonn9 Die: <br /> COMMENTS: Id)p��s \ ��4I� d n_�� sis i.1 yj„u.n , <br /> —� <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:icHEcK ALL THATAPPLYI <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 LIAP MUSHROOM CAT L3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby ceNfy that I ape prepared this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,end eta ,i' }'b/l♦�/p'N/0,m.haLS..�a �_ <br /> Signed �����i!i✓��-'`��.��> Title/Company SeMA a/ QP2f4"5 /1Ao &!504 /(4T Searle. On1b <br /> �' <br /> Print Name l\GtA.n 1•� Me(r.L.l1 Date 01/02/14 <br /> �lDEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 7b 00/,� T72EC'T I Gl'iTtf 4 <br /> WORK PLAN DATED J 1u)w42� ( I 2c,r V -1 , <br /> APPLICATION ACCEPTED BY DATE I N D � ptR LI <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 9,90 ( $125x 1 SR# G o)8 y 2 <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 WCWAIVER V 0-- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC nor✓/ <br /> EHD 29-01 6109112 WELL PERMIT APP <br />