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TYPE & # OF WELL/BORING INSTALLATION TYPE <br /> G_MONITORING liq_1-1OLLOW_STEM <br />0 EXTRACTION: Vapor! Water 0 HAMMER/DRIVEN <br />0 SOIL VAPOR PROBE 0 MUD ROTARY <br />3-- KSOIL BORING 0 PUSH POINT (GP/ CPT) <br />_0 INJECTION (i.e .Air Sparqe, Ozone( 5HAND AUGER <br />_0 OTHER: apTHER: WO NG' <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED: 0 Yes 0 No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />GROUT SPECIFICATIONS <br />{41-APPROX. BORING DEPTH 115 41--"- 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br />CONDUCTOR CASING 0 No 0 Yes: Casing Dia: Casing Depth: Boring Dia: <br />CONSTRUCTION SPECIFICATIONS <br />4.1/ (-In/ fr _DIA. OF_BOREHOLE t 0 MULTIPLE CASINGS 0 MULTI-LEVEL-WELL--CASING DIA: <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE SITE ADDRESS I/00 / evascmi 57 "7016 <br />I hereby certify hat I ye prepare <br />Regulatio d a icable Ca <br />Signed <br />Print Name <br />his appl' <br />rnia La <br />ion and that the work will be done in accordance with San Joaquin County Ordinances, RI41Jes and <br />1-kr.4-774_ FD-oT_ K-A2A 2A-14 Title/Company fl-kJi P-oN <br />Date /2_3 ; 3 <br />• <br />SAN JOAQUIN COUNTY <br /> FILE COPY <br />ENVIRONMENTAL HEALTH DEPARTMENT LOP <br />Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sjqov.orq/ehd UNIT IV <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <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 />vWcr (4. Site Location IAAt Cross Street rt-C-Att-6-44 'ROM) City STC.`X-1-1-00 Zip Q.C.-2-01— APN I 3? -o <br />Property <br />Owner CC-TS Address 0 c3 . )-(Cro-4 f Zip Ct 5( Phone Z-C>c (1.843-64 City I.CC. <br />C-57 Contractor K...kL*2_,,,,4 4 ftSCCC Address 114- LA). DOW-OTR- A-U_ City CA...0 Jt S Lic ,i/eioe Phone <br />k LC Consultant/Sub Cntr 16-9-/Q-A-14 A-SWAddress City Lic it Phone tt <br />Billable Party ii-P-A2-ikt4 ik; c L. Address 2-i S- EA). 1)14`. A-VE-City C)-6 i,.0 Zip 996 ( '2_ Phone 53-5 -3 e 2Z-Ca <br />GIS Coordinates: X <br />CONSTRUCTION WORK TO BE PERFORMED: <br />ritNEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) <br />SOIL BORING Ds <br />El WELL IDs <br />OTHER IDs <br />COMMENTS: <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 WELL(S) TO BE DESTROYED <br /> El OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br />WELL IDs: 0 PRESSURE GROUT To DEPTH OF FT BELOW SURFACE <br />GROUT SPECIFICATIONS El EXPLOSIVES FROM TO FT BELOW SURFACE <br />TREMIE TYPE TO BE USED: El AUGERS ID HOSE U PIPE <br /> <br />0 MUSHROOM CAP AT (3 FT) FT BELOW SURFACE <br />COMMENTS <br />5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />WORK PLAN DATED <br />APPLICATION ACCEPTED BY <br />GROUT INSPECTION BY <br />REA /9 .; <br /> FINAL INSPECTION BY 0,044<e4l DATE C5).00 <br />DATE <br />ACCOUNTING ONLY: AID # FAC # <br />PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE <br />REQUEST <br />RO # <br />PR # INVOICE <br />,2 ct05- $ 125 x / — °' <br />co / 4 q dc.)civTE.- 7 2 4/-1S SR# 6 ?&Es 5 RO # <br />(3500) <br />PR # <br />(2900) <br />DATE I <br /> <br />DESTRUCTION INSPECTION BY <br />COMMENTS/CONDITIONS: <br />-57 WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC