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FIVE CQ 1 <br /> iUL 15 2013 <br /> P ("• SAN JOAQUINCOUtF ndclafiLN=r1LiH <br /> ENVIRONMENTAL HEALTH DEPARTMM"I-95VICES LOP <br /> 1868 East Hazelton Avenue,Stockton,CA 95205-6232 SITE MITIGATION <br /> AiPs: <br /> Telephone:(209)468-3454 Fax.(209)468-3433 Web:www.slaov.oralehd 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 permit to construct and/or Install the work described. This application Is made In compliance with San <br /> Joaquin County Development'lille,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Sita Locellon 1162.464 <br /> <P7 Cross Street W4St Ln. . GlySrI6-k-+0YL Zlp2S'LOS ApN 111000(e <br /> Property <br /> owner_ LYnn*ire. Kent F•`f��- Address L��1 • �' ,�11 DiNt. /rVt. Cilyska�k'�'ah Zip 5205 Phone '':L01.133.1033 <br /> C-57Contractor AYli((aylnitUS)t'AV. Address 2`i 3(ot .Cn1-oN ndb S{'. City Aha Bim- Lic%1(759 5 Phone7)4. 238. 1122 <br /> ty 1 Lic PhoneO. '1 . 36 <br /> Billable Party i( Address It City II 21p 'X02 phone it <br /> GISCoordlnates:X (e7i�3S�l'S Y 2183'a.'7q An: Hya" <br /> @2NSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROSE.HYDROPUNCH,HAND-AUGER.OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDS KS <br /> OTHER IDs <br /> TYPE&#OF WE LL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _0 MONITORING ❑HOLLOW STEM DIA OF BOREHOLEY.Z •� <br /> 5-II' MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _O EXTRACTION:Vapor/Water O HAMMEWDRIVEN CASING THICKNESS TYPE OF CASING: Cl STEEL ❑PVC Q OTHER <br /> )�—WO1L VAPOR PROBE O,A MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS 0 HOSE (]PIPE <br /> A <br /> _(3 SOIL BORING APUSH POINT(OP/CPT) GROUT SEAL PUMPED:p Yes O No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _(3 INJECTION 11,w 0HAND AUG ER GROUT SPECIFICATIONS <br /> _O OTHER: ❑OTHER: APPROX.BORING DEPTH 40 F'+ 0 BOLTED TRAFFIC BOX OR (3 STOVE PIPE <br /> CONDUCTOR CASING 0 No❑Yea:Casing We: Casing Depth:_Bodng Dla:_ <br /> COMMENTS: 4-emF soilI& or v b.es '1) Iled c- Soil G s Adyisanf 1017— <br /> NOTE: <br /> 0 2.NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR VNCROACHMENI17 PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALLTHATAPPLY) <br /> _ff OFWELL(S)TOBE DESTROYED DOVER-BORE DIAMETER OF-INCHES TO DEPTH OF FT <br /> WELL IDS. 0 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS [J EXPLOSIVES FROM TO r•T BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERS (7 HOSE IfPIPE ❑MUSHROOM CAP AT(>-3 FT) FT OELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I prep rod is application and that the work will be done In accordance with Sen Joaquin County Ordinances,Rules and <br /> Regulations,and a a pi fomla Laws. <br /> Signed �'� Tllle/Company .v �dldC£a'L <br /> Print Name 4` nS Dale Z 3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS I G 2 y C /4 1,PI(L)E /4UE .1 <br /> WORK PLAN DATED JUW UI <br /> APPLICATION ACCEPTED BY J. `Joy3Kuvn DATE IS co <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE 4-0.-'I <br /> DESTRUCTION INSPECTION BY - DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAG <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATESERVICE RO# INVOICE <br /> REQUESTp�PR# <br /> Z o 5125X I 30 l8/ CDr-� Vl -13 sR# 6&-) <br /> 7.903 375 asOao <br /> PR# <br /> 2990 <br /> C•57 ✓ WC ✓ WAIVER _ C57 LETTER OFAUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOCS <br />