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SAN JOAQUIN COUNTY <br /> a. �� •.oma LOP <br /> EORONMENTAL HEALTH DEPART*NT <br /> :< SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> Telephone:(209) 468-3464 Fax:(209)468-3433 Web:www.siclov.or le ECEIVED <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATItG 0 8 2011 <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 application51(I$ pli�Ah�►iklkAll <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin t�nty Environmental Health DepartrRMMIT/SERVICES',/ <br /> Site Location l�/�S q Al.Nw4-V21 LY'?ross Street �. 5/��sLTo.�+' ,City -11U15eA) Zip 36 APN <br /> Property Pogt­ic W,4-5 M ,,// <br /> Owne&47V 4CL4 Qe�rn1-CO UIV 1:*_ Address 18/D a /f.4��� nw M*ity.STdG<�Dill Zips-Phone ZO4-768_,0?O <br /> C-57 Contractor VgjA/ bR l LLd AAq Ad�d�Nrvess319W bLJC L1 ae&5k RD City 5r 61rroN Lic y7_G 9e�=F Phone -10-7 <br /> ConsultantISubCntr�'7Sl�4tiE ,o A�,dt�inss �°��fl'[-�Ar�r)�ij�4 /�Y�L�Citu»�lZ/%i�7Q l�IYic�EZ/ PhonedS?�72&-'q67/ <br /> Billable Party/�°a �O 7'L�GbW l cRaaress -S�E City Zip Phone <br /> GIS Coordinates:X6D7196/,41< YZ1g7(,()i, l-" <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> 19 NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> (a SOIL BORING IDs fG� i ��� 3 e--Ci Al �c�r <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATION, <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE <br /> ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor)Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ,_❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL,rs EMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ISI SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes'Z No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e At Sparge.Ozones❑HAND AUGER GROUT SPECIFICATIONS A0l1 rZA7UA C43,y t-- 1/7— <br /> _❑OTHER: 1$OTHER: APPROX.BORING DEPTH /7//4 X —*) ' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> UGrt-"IP_ CONDUCTOR CASING PrNo❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS SC1tL S®R I N6cS /D`10' 91P2AZ°i QAoz rR?-) Aj�z'=- hA&L.JaR4­'�;1r� Ycs4�: .e; i4 c <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 ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM Ta FT BELOW SURFACE <br /> 'PREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 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 /> %Vulationy:!7 all applicablei ". <br /> monad Title/company l3��iSt ha Tic fav`cam <br /> Ptint NameDate 9131 I) <br /> DEPARTMENT USE ONLY PAYMENT <br /> SITE MAP IN UNIT IV FILE SITf ADDRESS RECEIVED <br /> WORK PLAN DATED -1 <br /> APPLICATION ACCEPTED BY feek±CL 1,n,wl DATE ISSUED l 7 A <br /> GROUT INSPECTION BY��.h.e,Pu.,A� FINAL INSPECTION BY RFJ�LNM t' <br /> DESTRUCTION INSPECTION BY DATE 1� <br /> COMMENTSICONDITIONS: T /Z q*uo <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 11 SR#09 <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />