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`0--V <br /> SAN JOAQUIN COUNTY " ORIGINAL <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232SITE MITIGATION_Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:WWW.siaov.ora/ehdREPM `� <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION OCT u 2 2012 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ��p <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the Work described. This application is ma�M �IsHE HEALTH <br /> Joaquin County Development TRIe1I Chapter <br /> �µ&11115.3,and the Slander a oof}the San Joaquin County Environmental Health Department. PE MITISER/V-IFE <br /> Site Location lol 5. Ul 1` rr 1� Omss Street ✓, r City Zip C� APN '�5,5p-0b)45 <br /> Property L ` n� c -(��I J A;4s Phone�u 1 J7"BqO� <br /> Owner I "1 Address �J) . Iv1 ;I[li City 5 Zip 5 <br /> C57 Contractor III 1U ������,q,Jd'ry�reA[ss CK4 � JVI City -1 ltmeYH�'D Lic _Phone ?—?� � <br /> Consultant/Sub nt S .Avif +YrrAbdress 14 nILX (�Ciry Lc Phone xrv�i-2o6Z <br /> Billable Party ,w)uS Env. (.. Address 3330 (amPal A,ttfiy City lllo wdak Zip2%92 Phone 53o'li2�—&Z <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> 1A NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> WELLIDs �—1 AtAvvyh Tid-5 75 <br /> OTHER IDs <br /> TYPE 8#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 3Ia it <br /> _❑ MONITORING 01 HOLLOW STEM DIA.OF BOREHOLE q Iq(MULTIPLE CASINGS Ep MULTI-LEVEL WELL CASING DIA: <br /> _t]EXTRACTION:Vapor/Water ❑HAM MER/DRIVENCASING THICKNESS riLL110 TYPE OF CASING 0 STEEL PVC p OTHER <br /> _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL~ 351 TREMIE TYPE TO BE USED'. ( AUGERS (QI HOSE ❑PIPE <br /> —❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yeses 1❑No(MA IMUM FREE FALL DEPTH IS 30 FT) r <br /> _',INJECTION Ii.e.Air Soaw.0zonel❑HAND AUGER GROUT SPECIFICATIONS ft ll'7�V1N <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH '1S I ea An ❑BOLTED TRAFFIC BOX OR []STOVEPIPE <br /> �� 1, � � INDUCTORCASING®No 0 Yes:Casing Dia: Casing Depth: Boring Dia:_ <br /> COMMENTS: O•,My IVB �rMLQ 71.0)Z, !A/TW./J I/wvl' <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY) rT <br /> �_#OFWEI�L(S)T aE DESTROYED OVER-BORE DIAMETER OF 10 NCHESTODEPTHOF CD FT <br /> WELL IDs: 11f *—10 [1 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Nod d" ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: DRAUGERS 60 HOSE ❑PIPE ❑ MUSHROOM CAP AT L3 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 all applplica/tile Califo 0-' -- <br /> —� __ Title/CompanySl �t /IC ( QIV0111r}�Signed - <br /> Print Name Date I OI 1 2)t 7 O,2 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED ICY .G4. DATE ISSUED .��iZS/eTAREA <br /> GROAT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTIO B�� DATE <br /> COMMENTSICONDI IMF/,/,I", .� ��i�i� /�7�'2 ��Iyi�. 77a7r"llg 3 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST RO# INVOICE <br /> EQUEST PR# <br /> $125 xSR#J116 0 <br /> 3 J 7 O 3500PR <br /> casco ��® � 0 <br /> (28B��6c23 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />