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,4P :. • SAN .JOAQUIN COUNTY • ORIGINAL <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> r° 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone.,1209\468-3147 Fax://209\468-3433 Web:www.siaov.org/eh UNIT IV <br /> ('F•�p'tP�p P I / l / <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 /> Application Is hereby made to San Joaquin County for a permit to construct and/or install the wok described. This application is made in compliance with San <br /> Joaquin County Development Title,,jChhap/ter Q9-11115.3,and the Standards of the San Joaquin County Emilirornmmen�tal Had&Department <br /> Site Location 3 9 j ,UeW r�N Cross�treet City/State Jux�p 4' .2 APN 13,2 <br /> Properly <br /> owner Klj f/h Address TJ3! /Uew4tJ PoAD Cdy/smtaSl�%C,&44,f LP gs:-Ais mn�20°�Q`fJ (aLl� <br /> C-57 Contractor N/A Address City/State Lie Phones <br /> ComsukwWSub Cntr S.( , MN)Ie- Address tZ 8a>< /sz W d /A�, ' — I xzv Phone 20 9-36 9-942/ <br /> Billable Party S, e>, MV/�e Address ct s ct 6 V el City/State Tm Phone <br /> GIS Coordlna[es:x Y -(2(• .258> 13c &vRe I 0�-ior2k"7�I�-r�7 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER OTHER) <br /> SOIL BORING IDs Fr7= <br /> WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WFILBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> /, `/ r <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE � // ❑MULTIPLE CASINGS❑MULTFLEVFI WELL CASING DIA 4/� <br /> ❑EXTRACTION:Vaporl Water ❑HAMMEMDRNEN CASING THICKNESS TYPE OF CASING: 11 STEEL ❑PVC ❑ OTHER <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMAE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑POPE <br /> `gSOIL BORING ❑PUSH POINT(GP/CPT) GROUT SELL PUMPED:0 Yes ff44o(MAXIMUM FR FALL DEPTH IS 30 FT)Murl'Cfr tit;S /"") <br /> 0INJECTION(ie Av Soaae.Ozoneh .HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX BORING DEPTH O-/<S' tr- ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> Z wit- <br /> CONDUCTOR CASING❑No Yes:Casing Dia: Casing Depth: Boring DW__ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLn <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 ❑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 I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and 11 appliSable California laws. <br /> Signed [�. P -'---r Tinercompany DCUNE/c' .S /Q. Pa�a <br /> Print Name ��/l V/�- <br /> Data 2 /3 / <br /> ? DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY ., ookKw` DATE ISS E11 ' AREA <br /> GROUT INSPECTION BY r FINAL INSPECTION BY TE <br /> DESTRUCTION INSPECTION BY DATE "I <br /> J _,, <br /> COMMENTSICONDrnONs: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMffTED CHECK# RECVD BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 35�S <br /> $130x / 520 ;-C, 10 EKE 7- Z'/o/S sR# 7t5&2 <br /> 3�� 3Ya Ro# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 WC Y WAIVERX/(11/(A- G57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EMD 29-01 7124114 WELL PERMIT APP <br />