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FILE COPY <br /> oulry - <br /> SAN .LOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N Opt � ;<I LOP <br /> I <br /> 600 East Main Street,Stockton,CA 95202-3029 SITE MITIGATION <br /> \\r P Telephone:(209) 468-3454 Fax (209) 468-3433 Web:MM.slgoy.oro/ehd UNIT IV" <br />! WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> . NON-REFUNDABLE PERMIT EXPIRES I 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 Heabh Department. .L an <br /> 1 - Site Location //6y7 <br /> Property .aveESI Y05ENI7-6 Cross Street $(24EH G'/U/ONldd- City MANTECA Zip APN <br /> .vuc <br /> Owner BR/AlK H6LMoAt OS 79(/5TAddress NU w,?OD ROAD All T-4 /City - LO3 &AIDS Zip Z/S03rJ Phone <br /> C-57 Contractor GR r 3A(441 Address '75n--Hord= ROA-0City MART/N ? Llc 41&'(65 Phone--T2—'L--3Z1­52-Lo- p <br /> ConsulfanbSub Cntr CRA Address /.y44q R(l/fQ5! )E DR City -5,1,V0MA Llcd SPhone 707- qS: -236/ <br /> Billable Party C'��-'7-RAddress !q�¢9/`'I VCRS/OF - ,)p. .City" 5oN,Pm j Zip 9Ss<76 Phone 7O 7 -933-Z;6/ <br /> GIS Coordinates:X__. 177 Y —/ z3 Y. . - „- - - - <br /> CONS <br /> T <br /> WELCTION WORK TO BE PERFORMED- <br /> ❑ NEW LIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> [:I SOIL BORING IDs <br /> ❑WELL IDs <br /> - ❑OTHER IDs <br /> A <br /> TYPE.&#OF WELLIBORING INSTALLATION TYPE _ CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION:Vapor/Water QIWMMERVDRIVEN CASING THICKNESS TYPE OF CASING. QSTEEL ❑PVC ❑ OTHER <br /> — <br /> ❑SOIL BORING Q PUSH POINT(GP/CPT) .GROUT SEAL PUMPEDL1Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _D INJECTION re Air Soame Ozmiet Q HAND AUGER . GROUT SPECIFICATIONS _ O <br /> _Q OTHER: El OTHER APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑.STOVE PIPE <br /> �i CONDUCTOR CASING❑No❑Yes:Casing Dia_ Casing Depth:._ Bonng Dia <br /> 'COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> D S <br /> TRUCTION WORK TO BE PERFORMED: " - DESTRUCTION METHOD: CHECK ALL THAT APPLY <br /> #OF WELL(S)TO BE DESTROYED - OVER-BORE DIAMETER OF_-Z INCHESTODEPTHOF 35 FT <br /> 9VELL IDs: M W-/ M W-L - y_ -. _ ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GRO <br /> UT SPECIFICATIONS _ -❑EXPLOSIVES FROM ToFT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS E]HOSE PIPE - ❑MUSHROOM CAP Ar L3 FT) FT BELOW SURFACE - Al <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 ali ppiicable California Laws. - - <br /> Signed - Title/Company S7-AF-f- e—OLO / CT <br /> Print Name - RF LCLJ Y/F2UDate OL-Q( -20/ 2 7 <br /> DEPARTMENT USE ONLY <br /> SITE.MAP IN UNIT IV FILE SITE ADDRESS fl`/ad lA/. %25fMrT6 Ayc-- i - mll n ri^ce <br /> WORK PLAN DATED J✓{(U / i 20 f <br /> APPLICATION ACCEPTED 8Y _ J-Y o,L Dr _ _ DATE 1 <br /> GROUT INSPECTION BY r. r'�'' e FINAL INSPECTION <br /> BY <br /> DESTRUCTION INSPECTION BY__ — j <br /> ~^_r DATE 12- <br /> ° <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# p <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE ! OSERVICESRO# INVOICE <br /> REUE/ T PR# <br /> 35oZ <br /> $125x 3 Z3 SR# Gy37� <br /> R°0 1g3q <br /> 750 . PR# <br /> (2900 <br /> C-57 ✓ WC v WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC_ _ <br />