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- ' <br /> 1,7 <br /> SAN JOAQUIN COUNTY <br /> T <br /> — ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 East Hazelton Avenue,Stockton,CA 95205-5232 <br /> SITE MITIGATION <br /> Telephone:(209)466-3454 Fax:(209)468-3433 Web.,www.s(vov.orD/ehd UNIT IV <br /> j ; •- Ii-O <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE NDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joaquin C Is hereby made to San Joaquin County for a Delmii to construct and/or Install the work County <br /> E described. This application Is made In compliance with Sen <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location a0b N- W C Cross Street City S' bt IL)ror Zlp 52.15' ARN 3-'-3 Ui <br /> Property ,` -{ <br /> Owner r Address 36 Glry c 11"Y1 P. Zip 87 Z' Phone 1)��' TJr2 <br /> C-57 Contractor . . Address St, Qc • City `/1tb. r\<7 Lb aas'ILs Phone QHS—213 V% <br /> Consultant/Sub Cntr •` Address 11' v City �rt.�:`�aS Lie Phone <br /> j Billable Party �,.pv iF_ Address b S 7;1" <br /> ;1 _ CI(y �Ylr:n ietS Zip 2671 Phone�'V'- ���`j-`1��'4 <br /> GIS Coordinates:X \'21 W D1 w Y 3Y)° SSN 3', Xg1'>\} <br /> CTRUCTI BE PERFORMED: <br /> NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER) <br /> SOIL BORING IDs <br /> WELLIDs W a` ' <br /> E] I OTHER O <br /> TYPE&p OF WELUBORING INSTALLATION TYPE �Q STRU TION I T O <br /> IL-10 MONITORING ❑HOLLOW STEM DIA OF BOREHOLE 's9 ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _O EXTRACTION:Vapod Water 0HAMMERIDRIVEN CASING THICKNESS 6V TYPEOFCASING: O STEEL Q4 PVC O OTHER <br /> _O SOIL VAPOR PROBE 1(KMUD ROTARY DEPTH OF GROUT SEAL VVI TREMIE TYPE TO BE USED: 0 AUGERS O HOSE 04 PIPE <br /> _O SOIL BORING OPUSH POINT(GPI CPT) GROUT SEAL PUMPED:Ayes ONo(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —0 INJECTION rte M,shame Oix,m O HAND AUGER GROUT SPECIFICATONS <br /> _0 OTHER: 0 OTHER: APPROX.BORING DEP,TTp,,H'''' O&SOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> �f� r CONDUCTOR CASINO pryeo 0 Yes:Casing Ola:_Casing Depth_Bodng Dla:_ <br /> COMMENTS: IANC\\ QiBS--_-\ - ��s h- Sc,rnr �'A M�..�s�— time 'S"r �(a )I SA �,y�?t'�,. ?Al N-.�,o X35 <br /> NOTE: OFFSITE WELLS&BORINGS R QUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS �S <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METH=(CHECK ALL THAT APPLY) <br /> ----P OF WELL(B)TO BE DESTROYED ❑OVER-BORE DIAMETEROF_NCHES TO DEPTH OF FT <br /> WELL IDs: [ PRESSURE GROUTTO DEPTH OF FTBELOWSURFACE <br /> 1 GROUT SPECIFICATIONS O EXPLOSIVESFROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE 0 PIPE ❑MUSHROOM CAP AT(i3 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 al lcab4C5 al fomla Ljws. <br /> Signed -- Title/Company /"YD1Qr.� �"�n'^ •� �T�1P <br /> Print Name Dale J- }fit- ZO\'v <br /> ,o DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS �I r '�n�-•-T /`fG Iu .$rd'e L'w4 <br /> WORK PLAN DATED 5-+?-9-12 ( <br /> APPLICATION ACCEPTED BY —1-Noo KV Y)A DATE ISSUED G-Z7-I Z AREA /— � <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK N RECV'D BY DATE SERVICE I RO q INVOICE <br /> REQUEST PR# <br /> 29c, / $125x 2 T -rq'r 2- SRtiW S/ <br /> ryg0 375' 3Glo�(P RD# <br /> 3500 <br /> PR# <br /> 2900 <br /> C57 ✓ WC r/ WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT VENCROACHMENT DOC NGL <br />