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opo to • SAN JOAQUIN COUNTY 0 FILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone: (209)468-3454 Fax:(209) 468-3433 Web:www.silaov.oralehd UNIT IV <br /> WELL & BORING PERMIT APPLICATION RECEIVED <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,i IJiN 18 2012 <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 Depa <br /> IRONMENTAL HEALTH <br /> Site Location 26577 Cross Street Vc..t W;c, Q-a• city Zr Zip 9 5177 AFIERMITt-cot /I2o"' <br /> Property <br /> Owner ILu�,e.\I Y-`,_ Address a6Ci77 Sl-c�mr 4s City Ye- Zip 9S�377 Phone 3o5-(oI- oS�-1 <br /> C-57 Contractor VW Lin IIkv . Address Po (los 97 D��D4@KC�ily 4.1 rrCnw Uc7tzhcLf Phone 2d± -36°1- ol 601!-, <br /> ConsultanVSub Cntr Address City Lic Phone <br /> Billable Party Mu,,i O\iJQ: Address iAr517 \/.K /Jtcm tb City "'Cfr-c-i Zip l7 Phone lora-7-7-5-7,$5 <br /> GIS Coordinates:X-I'U.q86XN Y '57. 7127_& ("Jvrov-) <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) Nr <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDS <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(I a AIr Soame.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> _1__#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OFINCHES T9 DEPTH OF FT <br /> WELL IDs: " PRESSURE GROUT TO DEPTH OF ?IQ 101 FTBELOWSURFACE <br /> GROUT SPECIFICATIONS ly Ge Wr'2K ❑EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT 7_3 FT) FT BELOW SURFACE <br /> COMMENTS a+'E, ly r a l a �JI-cAeJIL b Cc: ,.-,(L rx: '4- cr 'A$f 9 9 <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 /> Regulati ns,and all applic ble 9afifornia Laws. _ <br /> Signed Title/Company GAJ-OL-�j <br /> Print Name1 )v,, -� �=f� Date- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS{ l 5p0 V 16 N(60A0 LJ ILI 7rOgy <br /> WORK PLAN DATED JL4n,& . (UZUrZ- <br /> APPLICATION ACCEPTED BYUkJKU/+'t DATE ISS ED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY Z ir DATE <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 /> Zqp$ g125X I ?1e2L( SR# �Si37 <br /> ytb3 375- RO# <br /> 3? <br /> 3500 <br /> PRO <br /> 2900 <br /> C-57 /l WC v WAIVER Nil C57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOCS[ <br />