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SAN JOAQUIN COUNTY <br /> ' ENVIRONMENTAL HEALTH DEPARTMENT <br /> w t LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone:(209)468-0343 Fax:(209)468-3433 Web:www.socehd.com UNIT IV <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 pennR 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 Envuorimental Health Department. <br /> Site Location M 9 &&ML?&ft Cross Street W - f <br /> Props i" City/State ip as'�A', APN oZ Oq'UCV _f y <br /> Owner . "l tV"x1�-�LL CAddress t 1Ly Li Cjc.tcFe'm'it(-r`j'LSI u-�"k#I re4��'Ilp <br /> �CJ C-ZG(c0(Ztv'z-1/ CA- C�'SEr iz-C) <br /> — r <br /> c-ncontreete� Address 2724WRINVT}}Ver1UC cty/stete$ Llc S14[ Phone-q2 -.313-2T 7 <br /> J <br /> ConsultantiSub Cntr Address .3010(n A;,Ce4,,�m, CIVISteteLic Phone rIZS"395=Z.S� <br /> Billable Party Address 514 Z-SUCity/State _Phone <br /> GIS Coordinates:X Y <br /> C NSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> L]SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDS <br /> TYPE&0 OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _0 MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE [I MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> Ll VAPOR PROBE [I MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> �IRSOIL BORING PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yea 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION(,.,Arsoam&ora,at O HAND AUGER GROUT SPECIFICATIONS <br /> _O OTHER: 0OTHER: APPROX.BORING DEPTH' fI ti, O BOLTED TRAFFIC BOX OR OSTOVEPIPE <br /> //!!__ �� ,,,,tr C NDUCT CASING 0 No�Ya s nQ- ie: Casirp�Deplh: Boppg�Di <br /> COMMENTSL7fQUlallf, bUI IE.<,'+7?QL( !'t ,l,>l �ft��` c'� It L1C1,'.b>1[!10. (e 5 rta F'� i!. T�QU%I gT 7.44 Y7AS. <br /> NOTE: OFFSITE WELLS&BORINGS REQU RE ACIll AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> OF WELL(S)TO BE DESTROYED '�QyERZORE-DIAMETER OF_INCHES TO DEPTH OF FT <br /> WELL IDs:_ _ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO Fr BELOW SURFACE <br /> TREMIE TYPE TO BE USED_I]AUWRS-❑HOSE Ll PIPE 0 MUSHROOM CAP AT(>3 Fn Fr 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 /> Regulatlo d all applicabt California laws. <br /> Signed ,lR;�:, I`+1 Title/Com n I r <br /> Pdnt Name 0Q Date_ n <br /> / DEPARTMENT USE ONLY 0 — <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS l O G..� li c.u^L �r nOliLa.7��s bac �2rx :0 YLl 4-14 it7�-r <br /> WORK PLAN DATED / S <br /> APPLICATION ACCEPTED BY ---- DATE ISSUE / A A <br /> GROUT INSPECTION BY FINAL INSPECTION BY ATEu �� <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: O /1 <br /> ACCOUNTING ONLY AID# FAC# <br /> DECODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> agCls s130X q tl 3 90,00 Gl C, SR# <br /> yM 1� 4-031ZSC R'# <br /> 7600 <br /> PR# <br /> 2900 <br /> C-57 1C WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 1 7/7/2424/14 WELL PERMIT APP <br />