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TYPE & # OF WELL/BORING <br />2 %MONITORING <br />0 EXTRACTION: Vapor/ Water <br />SOIL VAPOR PROBE <br />0 SOIL BORING <br />INSTALLATION TYPE <br />RHOLLOW STEM <br />HAMMER/DRIVEN <br />0 MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT 0 RtGZIAL <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sislov.orqlehd <br />WELL & BORING PERMIT APPLICATION , <br />SITE M TIGATION <br />UNIT IV <br />FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION • + <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED P-,,(4.,/- f".v <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 />4i,4 V1e1C4l Site Location i 9'09N S" Cross Street (--.% - W01414" City/State 5rve1oav Zip q5-2-o6 APN Property A _ <br />Owner /i/riCti C4-41 i/k INA5TO 1 e- (424PAddr'reiss 2t0i G-6tAPSPA"V5r. "City/State 64-66,009A- Zip/ i/q0 Phone qCq- o,"4-. 7336 <br />C-57 Contractor eetseewk Deiii;f0, Address 3000 DIA /edit Sired City/State ed,sactust e 9 .3b/c) Phone `2/6- 6 3E-P67 <br />Consultant/Sub Cntr 6/1D, /NC-- Address 2z 35- /116-eompr 14/44 4/to City/State44i4.Lic eC"ii164i Phone '967-523 to/ o <br />Billable Party c)444 Address City/State Zip , Phone <br />GIS Coordinates: X <br />_ <br />Y .411P - 6 L-kft 3g7. 1 4 s-7o6°, t,of,v; ,-7-1, <br />3 <br />z4504vs-4 ?.'1'151-'7 "UV Aer.., es Al w --4 t4-r.: 31. cf te.5- 63e , /,,w6 ..- i 24, a So 866 ° <br />CONSTRUCTION WORK TO BE PERFORMED: <br />D NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) <br />0)SOIL BORING IDs , NWELL IDs Ai k/-7;) /14 IA1 --I- D OTHER IDs / <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE S h 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: a <br />CASING THICKNESS lel. (10 TYPE OF CASING: 0 STEEL al5C/C 0 OTHER <br />DEPTH OF GROUT SEAL 'ZA TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE XPTPE <br />GROUT SEAL PUMPED: 851.".>0 No (MAXIM FREE FALL DEPTH IS 30 FT) AO ttc.A4,2DAY, <br />GROUT SPECIFICATIONS 1tt24.4,/ 157 (tit, <br /> <br />BOLTED TRAFFIC BOX OR El STOVE PIPE ' <br />COMMENTS: <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />DESTRUCTION WORK TO BE PERFORMED: <br /> # OF WELL(S) TO BE DESTROYED <br />WELL IDs: <br />GROUT SPECIFICATIONS <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />0 OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br />0 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br />0 EXPLOSIVES FROM TO FT BELOW SURFACE <br />0 MUSHROOM CAP AT (•3 FT) FT BELOW SURFACE TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />COMMENTS <br />INJECTION (i.e .Air Spam, Ozonel El HAND AUGER <br />0 OTHER: o OTHER: APPROX. BORING DEPTH <br />CONDUCTOR CASING k5r1 -o 0 Yes: Casing Dia: Casing Depth: Boring Dia: <br />5-o 1 <br />5 WORKI <br />I hereby certify th <br />Regulations, a <br />Signed <br />Print Name <br />AYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />e prep POrAitliS application nd that the work will be done in accordance with San Joaquin County Ordi ances, Rules and <br />pplicable alifornia la s. <br />Title/Company <br />R,10.1) <br />go3 ex-T -- <br />Date 7//&/.2riiel <br />&hi> <br /> <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS . 3.2(3 rvi6 T 570A )77,z) <br />WORK PLAN DATED ?9 , <br />APPLICATION APPLICATION ACCEPTED BY J • j 0 a•KL./...v-N. <br />GROUT INSPECTION BY /f/g/G/ <br /> <br />DATE ISSUED <br />FINAL INSPECTION BY <br /> <br />AREA /6 9, <br />DATE 2/49/45" <br /> <br />DESTRUCTION INSPECTION BY <br />COMMENTS/CONDITIONS: <br /> <br />DATE <br /> <br />ACCOUNTING ONLY: AID # FAG # <br />PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE <br />REQUEST <br />RO # <br />PR # INVOICE <br />O ( $ 125 x 9•-• af 2,5- I 7 -3 6 O Z_ dpctivi-Elt, ?-t8-1,1 sR# 0(3.8 <br />\ <br />290 S T75- RO # <br />(3500) <br />PR # <br />(2900) <br />-57 1..V WC WAIVER kt.d a- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br />FA-1D 29-01 5/09/12 ENCROACHMENT DOG <br />WELL PERMIT APP