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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone: (209)468-0343 Fax:(209)468-3433 Web:www.sicehd.com UNIT IV <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 work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> "I • 7ey bitV.1 Y ciSite Location Cross Street C4OVEX Qt9ACity/state zlP537-4- APN ;+1180-641 <br /> Properrttyy � VR <br /> Ovmer(�I IfGfl pr4rtfrNE45�17' Address�•0.B4k 37C1�O�r0,,,`��ih Gity�a�ep N✓ zip 8931 phone415.417-5791 <br /> C-57 Contractor A Address 2NSA '11MM1 IYs.IF+ DR. &e 7755, <br /> L.is G95q 7U Phone 9lL-'FI?•4858 <br /> ConsultanVSub CCntr ARirNEl L2K Address115410R44MC U City/Staliea"a"'���'Cic�7���Phone 4i"351-F10'7 <br /> Billable Party Is I_:p f Address AO-s 3765T ,g Lr&AI M'Zip aT rte' Phone Olt-00-599/ <br /> GIs Coordinates:x37' S3 a ly 121' 2( 11.0"W <br /> CONSTRUCTION WORK TO BE PERFORMED, <br /> ❑NEW WEOIL BORING G(CP ,GEOPfip HYD _pl CCH,2W-!�,€{{,OTHER) <br /> WELL IDSy' tt'!C U�►1 1�IJ <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA,OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_ <br /> _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE ❑PIPE <br /> I3-1a SOIL BORING IqPUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yesallopp(MAXIMUM FREE FALL`pEPTH IS 30 FT) <br /> _O INJECTION ile far si a e oannar❑HAND AUGER GROUT SPECIFICATIONS /�G�T �+•14aN/ <br /> _0 OTHER: O OTHER: APPROX.BORING DEPTH IS ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> 1 k IESCFd 9119 CONDUCTOR CASING❑No❑YYes:Bqasing Dia: CavnypeDth: Boring Dla: <br /> COMMENTS: 'DO�1N65 ,Tt_'MP GW CO LLf 71 pYtlr 2 301( Y $p�A3�,C <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTIONMETHOD•(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ❑OVR- <br /> EBORE DIAMETER OF_INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS C]EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑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 I have prepared this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and I'k (Ilc Is C Ifornia I <br /> Signed / Title/Company 5CA)I* W.AIA4A6, --?AR.?A1 X >c5Z <br /> Print Name . 110R RILL-- Date 6'• 4- "16' <br /> 2 �j DEPA TMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 3O F I fU <br /> WORK PLAN DATED M0 a .2415 1 <br /> APPLICATION ACCEPTED BY DATE ED WEND <br /> GROUT INSPECTION BY FINAL INSPECTI INS Y <br /> DESTRUCTION INSPECTION Y DATE � <br /> COMMENTSICONDITIONS: wZXZ ..- <br /> ACCOUNTING ONLY: AID# FAC If JOAQUIN C <br /> UA <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVIC D L TY <br /> j1 � QQ REQUEST PR <br /> 290 S $130 X D I.G GILL. UJ S�S�/S • SR# Z <br /> Com'/9loaza ;00 <br /> PR# <br /> 2900 O <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOCNIT <br /> EHD 29-01 7(24//4 WELL PERMIT APP <br /> r\No019olog <br />