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SAN .�OAQUIN COUNTY <br /> �o. .coG LOP <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N SITE MITIGATION <br /> ,• 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> • q.., : .�;iP Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:www.sagov.ora/ehd <br /> 1OD <br /> � FR <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REPEDIATION NOV 2 4 2010 <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 madfWO NMENMISMEXTH <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environment Health Department. PERMIT/SERVICES <br /> 1 cS AvE. 260 <br /> Site Location�1 7 W Y 6M��Cross Street �/SFl•BA�K 12QCityM4�-f2�>�' Zip q5:-?,?7 APN <br /> Property �; <br /> Owner KA•/�S6R PEam,GFN9Fn�?E Address 2 1"N-60 Pr•47A City 0AKL�wr� Zip 4. -- Phone ✓()—?71-3-1/0 <br /> C-57 Contractor V jK&A)rz X Address Wfi CJAA446N66 D2. City C•dN<OAD Lic-7659Z.Z Phone 9ZS-9"-(.9-70 <br /> Consultant/SubCntr PAPAS Address 3620 6)(Pi-0(Ll5a 09. 4'51 City.SACAAA'if4K> Lic733'07 Phone ?/`'57•'/"/ <br /> r7 <br /> Billable Party CAD 2'E Address S0446 AS A AVE„ C� Zip Phone <br /> GIS Coordinates:X 3�• �� Y (� • �'y�' t \ <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYD OPUNCH,HAND-AUG R,O R) <br /> -ASOIL BORING IDs -/ --I <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE C TR ION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM OF 6V0REHOLE 2 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN 9S1EAL <br /> HICKNESS TYPE OF CASING: El STEEL El PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE E]MUD ROTARY / F GROUT SEAL'_TREMIE TYPE TO BE USED: ❑AUGERS [I HOSE PIPE <br /> Pk SOIL BORING �pUSH POINT(GP/ PUMPED:❑Yes $,No(MAXIMUM FREEZE/FALL DEPTH IS 30 FT) <br /> _E1INJECTION(i.e.AirSoarge,Ozone)F1HAND AUGER GROUT SPECIFICATIONS 'PO(LTL+4 t9 it J/o <br /> _❑OTHER: ❑OTHER:T APPROX.BORING DEPTH 0 l5 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTSJF GW ENC6v/V7F>O 1 o L <br /> NOTE: OFFSITE WELLS& BO INGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <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(?3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS TICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I havffl <br /> d this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations, d applarfornia laws. <br /> Title/Company <br /> Signed �nOt�&CT G�G�o6l,�"J'� ���� •¢ff�. <br /> Print Name L qN GJ44 c L Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FIL -SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# INVOICE <br /> $122x Ch \ \Z ` SR# Q0&P17 <br /> tf <br /> RO# <br /> 3500 <br /> ssoo <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PER I NCROACHMENW DOC ELLERMIT APP <br /> EHD 29-01 07/28/10 ,,�\� �`Q <br />