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01/10/2014 15:41 FAX 9153722565 WALLACE-HUHL AND ASSOC. Q002 <br /> ptj�� �on�vn��ia. N�,A-•der: 0?-7 <br /> EIV <br /> /Eq SAN JOAQUIN COUNTY <br /> �/ NVIRONMENTAL HEALTH DEPARTMENT T <br /> �� 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> one: 209 468-3147 Fax: 209 468-3433 Web:w1Mw.sigov.orD/ehd <br /> ENVI�ENTRELL & BORING PERMIT APPLICATION <br /> LMW*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 Canty for a permit to construct and'or install the work described. This application is made in compliance with San <br /> Joaquin County DesVpment Title, <br /> /1'Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department <br /> Site Location �4T. O°is'7u� f rosa skeet S.T cny/staleW/1z": <br /> 37 APN �' 1001 <br /> Property - y Qi(`'�)(� �...e p 7n��r <br /> Owner 1 �_ c�4ddress I LDN I CitylSlales-�✓�r(aI� Phonetil l" 030-3NC-57C..V or Q (Address City/State . Phone <br /> ConsultanU3u11b��,,Cntr Address City/stale�ic An Phone Q (�X77 <br /> Billable Party rM,� — ,A Address SQj CKy/state Ip,��Phone—ilk-4-411--Puy <br /> y <br /> GIS Coordinates'X 37.'12 /U Y UVII, aW ���1'�� <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING CPT G OPROO�� HYDROPUNCH.HAND-AUGER,OTHER) <br /> 59-SOIL BORING IDS TQC <br /> O WELL IDs <br /> 0 OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _(]MONITORING (HOqLLOW STEM DIA OF BOREHOLE �❑n MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> e <br /> _❑EXTRACTION.Vapor/WMr ❑HAMMER/DRNEN CASING THICKNESS At IA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE JLMUD ROTARY DEPTH OF GROUT SEAL IS-SD, TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE (a PIPE <br /> _5_1%SOIL BORING ❑PUSH POINT(GP!CPT) GROUT SEAL PUMPED:❑Ye^s-G No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION Ii.e n S,atii,.0, ❑HAND AUGER GROUT SPECIFICATIONS at;%I I U LIA/IV <br /> _❑OTHER: ❑OTHER:- APPROX.BORING DEPTH W-571, EASOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> �T - <br /> CONDUCT �No[I Yee:Casing Die: Casing Depth Boring Die:_ <br /> COMMENTS <br /> er <br /> NO : OFFSITE�WELLS& OR GP <br /> EBN INGS R6 U R ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTROCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO SE DESTROYED ❑OVER-BORE DIAMETER OF INCHESTO(1EPTH OF FT <br /> WELL IQs: O PRESSURE GROUT TO DEPT«OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS O EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED.❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(?3 FT) FT SELOw 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 Sal Joaquin County Ordinances.Rules and <br /> Regulations,and II plicabl California laws. t <br /> Signed _�� (�u'�^�--.�� Tile/Canpam IS4/�(o! E"If AK AL�Att kyL�� kltt of <br /> Print Name ll Stu Date_I nA//4W <br /> DEPARTMENT USE ONLY / <br /> APPLICATION ACCEPTED DAT REA /74y� <br /> GROUT INSPECTION BY INAL INSPECTION BY DATE {/ I'"'�'� <br /> DESTRUCTION INSPECTION B DATE <br /> COMMENTS/CONDITIONS: GEOTECHMCALONLY '' <br /> ACCOUNTING ONLY: AID FAC# <br /> PE CODES S CAMT REMITTED CHECK# RECV'D BY DATE SERVICE INVOICE <br /> REQUEST <br /> 13 sR# 081A <br /> RO# <br /> 3500 <br /> PRO <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EMD 29-019iDB112 <br /> u' 6 Cid jWELL <br /> PERMIT APP <br /> �GC #0-27Z <br /> OF <br /> C4rl— z -ZILf.Q6CEZCII s 490im -r /Dot/; flGZab-ff-chi !�- <br /> dwe441—PtZ exl.F 41ciuBf% <br />