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2-ft <br /> C;E Y <br /> 1pq SAN JOAQUIN COUNTY <br /> MAN or <br /> i LL lit" <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton, CA 95205-623211RONMENTAL HE/MUNIT IV <br /> Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.sjab <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 /> Site Location .?05D 6, 1�0&160 Cross Street A�cr_lide;V 014P. City/State ip APN <br /> Property,D,J*bm(504) 4LC q <br /> Owner —tec,- 1,-VC- Address 750 IVV ciot,4mbi_4 zlivA C i t y/S t a t e PO-11�A�V`14 <br /> � _77 i p 7,411 Phone <br /> C-57 Contractor C­o��0c—_6— 0/0�1,04&Address 95D Alt9Wc_ 4Al) City/State 1"I'l'�7AIIV"?'Lic qo*'5'1(a 5 Phone 19,!; <br /> Consultant/Sub Cntr AX'ZR121S Address �41 City/State A��4 a Lic Phone 916. <br /> Billable Party 1XC_1q19117 Address City/State Zip 'K&V, Phone 51& <br /> GIS Coordinates:X 57.!?C`W.Q Y — /al 003 <br /> 3?-u O —124. <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> SOIL BORING IDS <br /> J.RrWELL IDS 04 ) /-J,,/- <br /> //_ 7 7 <br /> go <br /> a�_Lll�775 7 AP, 17", 72,7377�90 1 <br /> [I OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING E3 HOLLOW STEM DIA.OF 13OREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION:Vapor/Water El HAMMER/DRIVEN CASING THICKNESS .� 'A <br /> 4 , TYPE OF CASING: 0 STEEL APVC 0 OTHER <br /> _E]SOIL VAPOR PROBE AMUD ROTARY DEPTH OF GROUT SEAL VA/Z/ TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE PIPE <br /> _O SOIL BORING [3 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:,KYes El No(MAXIMUM FREE FALL DEPTH IS 30 Fr) <br /> _[]INJECTION fi.e.Air SDarae.Ozone)El HAND AUGER GROUT SPECIFICATIONS ,VM-r 1_�AlbeVl <br /> _[I OTHER: 0 OTHER: APPROX.BORING DEPTH XBOLTED TRAFFIC BOX OR El STOVE PIPE <br /> CON SING ANO 0 Yes..Casing Dia:—Casing Depth:_ Boring Dia:_ <br /> _C%�TOR CA <br /> COMMENTS: M�� I'd jm�, e :�Al 3-0V/4; <br /> NOTE: OFFSITE WELLS &'BORINGS REQUIRE ACCESS/AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF W ELL(S)TO BE DESTROYED Ej OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: El PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS [:1 EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:El AUGERS []HOSE El PIPE [I 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 /> Regulation ,and all applicable California laws. <br /> Signed 15 Title/Company C10/"i'1 9 r,4 ux_s <br /> Print Name cott (4e-r_%c_v-,c Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 7?7 �,qt2z kir <br /> WORK PLAN DATED Amj%umww a2rdEDW <br /> APPLICATION ACCEPTED BY 0 41"tt4ks✓t DAT I ''REA <br /> GROUT INSPECTION BY FINAL INSPECTION BY Zil 10 0 4 awCATE <br /> DESTRUCTION INSPECTION BY DATE U U <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> REQUEST PR# <br /> $ 130 x 7 0 CA JV TV�L SR# 7147V <br /> RO# <br /> (3500) <br /> PR# <br /> (2900) 00016 r5t <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT IZ ENCROACHMENT DO <br /> EHD 29-01 7/24/14 WELL PERMIT APP <br />