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i <br /> DECEIVED <br /> i <br /> ¢uta SAN JOAQUIN COUNTY JAN 2 7 2011 <br /> y.• .•-•�•,-. ; LOP <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION <br /> ENVIRONMENTAL HEALWW IV <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> •:- a• Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.slgoy.or <br /> i �fkaR�' <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicatlon 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 9-1115.3,and the Standards or the San Joaquin County Environmental Health Department. <br /> Sltel.ocation lwr 140;1 ' 9 Cross Street City Craw o zip MW APN Ot}-OQD-36 <br /> Property CIA" W kkr — <br /> Owner �Gslrti O.11 SutCaJinc, Address 8656 Weal A R-re.. Cily zip q'SgZB_Phone 91L-383-!}S 6 <br /> y C-b7Cantractor (7Tcyy'Dti�lin-A Address SD ode. 3ka, City NiLicY8516sPhone IZ+r-3t3 S$DO <br /> Consuttant/Sub cntr'�jJL4 - 1; alkcr tt'Address Aq,-, Cityuf0j 0._ Lic ftonrs A '`� t•$�SS� <br /> I Billabla Party � c � �'1t15��,1ay Address $S'SC Wcu j4.A Au,-. city .» . zip Phone 9i6-3a3-1}i b <br /> tGIS Coordinates:X Y 38. i SS <br /> JQNSTRUCTION WORK TO BEP R ED: <br /> JJJLI NEW4Vj LUGORING(CPT,GEOPROBE,HYOROPUNCH,HAND-AUGER,OTHER) <br /> { Q • RING IDs <br /> j ©WELL to$ <br /> 1 ❑OTHER IDs____ _ <br /> TYPE&#OF WELUBORING 1NSTA ON 7YP w CONSTRUCTION SPECIFICATIONS <br /> I �]MONITORING ❑HOLLOW STEM DIA OF BOREHOLE C]MULTIPLE CASINGS❑MULT]-LEVEL WELL CASING DIA <br /> _O EXTRACTION Vaport Water ❑HAMMER/DRiV£N C THICKNESS TYPE OF CASING: ❑STEEL C PVC O OTHER <br /> l _O SOIL VAPOR PROBE t]MUD ROTARY DEPTH OF GR TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE Q PIPE <br /> S <br /> _O SOIL BORING Q PUSH POINT(GPI CPT) GROUT SEAL PUMPED: No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> `0 INJECTION d,e.nc Swrae.Oza e1 HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: O OTHER APPROX.BORING DEPTH _ LTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia' Casing Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERM <br /> DESTRUCTION WORK TO BE PERFORMED: DESTTI ET aD: I Tn <br /> #OF WELLS)TO BE DESTROYED OVER-BORE DIAMETER OF tf INCHES"O DCP111 OF 6� FT <br /> LL -E IDS:_ MSS—I , A40-Z. MU-3 A MO—4•4 PRESSURE GROUT TO DEPTH OF 3 �� FT BELOW SURFACE <br /> GROUT SPECIFICATIONIS r EXPLOSIVES FROM 70 FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:',AUGERS ❑HOSEPIE EIUSHROOM PAT(?3 FT)_0 - FT BELOW SURFACE <br /> COMMENTS -1 ,# w (��_�sir �t4o-2. � M W~�f (,o'icrdr�W <br /> 5 WORKING DAYS NOT CE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby ce that I have prepare this pplication and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, a bte Call mia aws. <br /> Signed Title/Compan t-& <br /> Print Na __ DataT <br /> DEPARTMENT USE ONLY I <br /> SITE MAP IN UNIT IV Fit- -SIT ADDRESS /92-5b tk'Cu -79T�ACrt r�O �� Svl.c <br /> WORK PIAN DATED / 3 doll <br /> APPLICATION ACCEPTED BY DATE ISSUED <br /> GROUT INSPECTION BY FINAL IN TION BY DATE <br /> DESTRUCTION INSPECTION BY DATE �� N <br /> COMMEtTSICO NDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# _ <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> 22 x <br /> REQUEST j PR# <br /> 1 _- -� -.303 966- swo <br /> 3Gb_ 31-6- a on1460d6Zl <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> IIID 29.01 07/28/10 --" �- - WELL PERMIT APP <br />