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GIS Coordinates: X da <br />DESTRUCTION WORK TO BE PERFORMED: <br /> # OF WELL(S) TO BE DESTROYED <br />WELL IDs: <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED: El AUGERS I=1 HOSE LI PIPE <br />COMMENTS <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />CI OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br />0 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br />LI EXPLOSIVES FROM TO FT BELOW SURFACE <br />0 MUSHROOM CAP AT (?.3 FT) FT BELOW SURFACE <br />Site Location 2,0 5 - AnazicAllar;is Street (. twog-1-74 City/State )Q,KTIA1 zip e75,./ci;) APN P/3 -',2 9;k1 I Property <br />Owner r <br />„ <br />lfiet, 4 <br /> , <br />Ai <br /> <br />fall <br />-g-7--L„", .a <br />•" <br />i <br />- <br />d <br />- <br /> j <br />A <br />a <br />d <br />d <br />d <br />i <br />r <br /> 0 <br />e ss X / <br />„ <br /> ,7 / 4 r eC.- "hie_ City/State d711 NOV/ Zip q 5 20 CF'hone ),.°1 '117.0 • 344) 5-- <br />-11/' Address 3600 Da-/1 Streef City/Statie`Sict-ditte4) q5k//0 Phone 9/4-43g--)/69 <br /> <br />zz, 3S— A ekelAte- S' W-11i City/State 54A4-4110-4- Lic P6r #57611 Phone -7 6-4- 523q0/0 <br />Billable Party '..44-141C9-f Address rt 15-1) City/State Zip Phone <br />c..44-: 161 (1 S%0 L421V6 ! 12-1 . Z. i 3° <br />0 OTHER IDs <br />LOP <br />1868 HazeIton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br />Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.siqov.orq/RECtIT <br /> tD WELL & BORING PERMIT APPLICATION <br />FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATME 18 2014 <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 imiptoNmEtaildomiti <br />Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Depart <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />R13E/WIT/SERVICES <br />C-57 Contractor <br />Consultant/Sub Cntr (7 Address Address <br />. (152.,1-( -121. ;425;1 PO <br />CONSTRUCTION WORK TO BE PERFORMED: <br />El NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) <br />El SOIL BORING IDs <br />SWELL IDs AM/ - 5 Am), 8- <br />,ehx( '9/1 3/1 5 <br />TYPE & # OF WELL/BORING INSTALLATION TYPE <br />IA-MONITORING g<OLLOW STEM <br />0 EXTRACTION: Vapor/ Water ID HAMMER/DRIVEN <br />1:1 SOIL VAPOR PROBE 1:1 MUD ROTARY <br />0 SOIL BORING 0 PUSH POINT (GP/ CPT) <br />El INJECTION (i.e Air Sparee, Ozone) CI HAND AUGER <br />0 OTHER: El OTHER: <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS it <br />DIA. OF BOREHOLE S 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: a <br />CASING THICKNESS '5CIA WC) TYPE OF CASING: 0 STEEL IN<JVC El OTHER <br />DEPTH OF GROUT SEAL Z TREMIE TYPE TO BE USED: El AUGERS 0 HOSE 1511-.DIPE <br />GROUT SEAL PUMPED: Lefes 0 No (MAXIMUM FREE FALL DEPTH IS 30 FT) Atic) Peop7adv, tzr <br />GROUT SPECIFICATIONS •ory(2 Pm AV trr <br />APPROX. BORING DEPTH 50 e-30LTED TRAFFIC BOX OR 0 STOVE PIPE <br />CONDUCTOR CASING IZKo 0 Yes: Casing Dia: Casing Depth: Boring Dia: <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />application nd that the work will be done in accordance with San Joaquin Count Ordinances, Rules and ex.t.i <br />alifornia law . <br />I hereby certify th <br />Regulations, and <br />Signed <br />Print Name <br />e prepa <br />pplicable <br />RY(AI CRAtvote-..D <br />Title/Company Pfee3ec,r- Wco ( 197 — 6 <br />Date 7ba,20/4/ <br />WORK PLAN DATED 0-‘2414 19 1 2-0 14 <br />APPLICATION ACCEPTED BY 1019 ,(1-‘ <br />GROUT INSPECTION BY Afre 41140 <br />DESTRUCTION INSPECTION BY DATE <br />COMMENTS/CONDITIONS: <br />C-57 I/ WC WAIVER /04_ C- <br />EHD 29-01 5/09/12 1A/P1 I PFRMIT ADD <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS 8ge-) 5. A ME 2 ,e p4k) 5712.<€7, rk7K.?Cl/J <br />DATEVED 7-2 /— t-t AREA <br />FINAL INSPECTION BY ii•G/A-01,1€/Jv 4 DATE g720/1 5- <br />FAC # <br />CHECK # RECV'D BY DATE SERVICE <br />REQUEST <br />RO # <br />PR # INVOICE <br />1"736 OZ dc-)c.e/uret. 7 - /8,1c/ sR# 7o6 C( (4 14(0/1 t <br />RO # <br />(3500) <br />PR # <br />(2900) <br />ORIGINAL <br />2-90 Scx2 <br />2,90 <br />$ 125 x <br />3 7 --• <br />FEE INFO <br />AID # <br />AMT REMITTED <br />ACCOUNTING ONLY: <br />PE CODES