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�.... - ... ---------- <br /> SAN <br /> -SAKI JOAQUIN•COUNTY <br /> ENVIRONMENTAL HEALTH`DEP.ARTMENT LOP.':::. <br /> 1868 Hazelton Avenue Stockton CA 95205-6232 SET.E M�TIGATIQN <br /> Telephone: (209) 468.3947 Fax X209)468-3433 Web:tuww.sigov.Orgteh UNIT.`!V <br /> N�fFpRa <br /> ;WELL.& BORING PERMIT APPLICATION.,— :. <br /> FOR WELLS AND*13ORINGS;U.SED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE:ISSUED. <br /> Application is,hereby(Wade to San Joaquin County for a permit is construct andlor rnstall the work descnbed:`'This application is made In compliance.With•San <br /> : Joaquin Copnty Development Title,Chayptter 9 1115.3 and the Standards of the San Joaquin County Environmental Health Departm6n't. <br /> Site:Location Ito COIN"&( Cross Street T�Q���V'd: City/State S�zip <br /> Propertyq <br /> Owner•�('/Y1Lra �lAl{r1�Sclraddrt ss JS�S h!.Loruclt . aty/State zip 953 Phone a-324 <br /> - i s: <br /> C-57 Contractor. GAS �f+.�'1AaJ Adoress*3 w�►.117 R CitylSta�&zLr lie-h Lic:931l)D Phone�l6�63$- <br /> ConsultantlSub Cntr; Address 5qM uDI�iS S SSC : C1ty/State '' ((www LIC. Phone �) J'j�-b�00 <br /> I3rllable <br /> Part y G � (: Address Clty/State Zp Phone <br /> GIS Coordinates:X'4.�yq0�f Y 2l `: <br /> Ifo 2 t:�•l k(a +�., -:.; ... I': <br /> :: ...... <br /> CONSTRUCTION.WORK TO BE PERFORMED: <br /> . ....:::.: .: . <br /> EW WELLIBORING(CP7`;'GEOPROBE HYDROPUNCH HAND AUGER OTHER) <br /> Ek8OIL BORING A— ��,A- Q 4. <br /> El WELL IDS';::%: <br /> F71 OTHER IDs <br /> ' <br /> TYPE&#OF WELL/BORING:`. :..JINSTALLATION TYPE CONSTRUCTION SPECIFICATfON5 <br /> _'I�.ivIONITORING O.HOL)OW STEM DIA.OF.$pREHOLE _ AD MULTIPLE.CASINGS�MULTI--LEVEL WELL CASING DIA:. <br /> DC7RACTION:Vapor!Water ❑HAMMER/DRNEN GA$ING,Fl11CI(NES$ ' JVQ TYP)=OI CASING t7sTEEr <br /> I <br /> SOIL-VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT.SEAI TREMIE TYPE 13E;i1SE4;'.p AUGERS: HOSE.. <br /> _/ zs . ..... : . 4 : . '. <br /> FOIL BORWG IPL7$H POINT.(GP/CPT) GROUT SEAL PUMPED ❑Yes d No=f.REEI:.A(LpE�TH.I$:�0 <br /> : .:.: . <br /> OJNJI=CT.IONtFe:AirSoa�e.ozonell]'HgND ER;'.. ! C�R00F;SPECI6ICAT-IONS' `"' <br /> 777 <br /> 0 OTHER:: ' ❑OTHER:T�_:APPROX.BORING DEPTH 2S { ❑BOLT' DTf2AFFIC;BOXS:OR 'QSTOVEPI E <br /> j� CONDUCTOR CASING❑No❑Yes:.CasingDla: C slog Depth:`'.` g77 , <br /> oring Dia:' <br /> • <br /> COMMENTS: + Dtr� PV51f+ bVr;llgs 4}p .� 11t4I1[r L -4 fv ( I�c�r p�afe^�1UUAdwtl Irl OTs. <br /> NOTE- OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS`OR ENCROACHMENTPERMITS. I <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD (CHEtkALL THAfj RL?l1 i: `.: : ....... <br /> #OFWELL(S)TOBE DESTROYED 0.'OVERBOREDIAMETEROF; " NCHESTODEPTH OF FT.'. <br /> WELL IDS .. ❑PRESSURE GROUT TO.DEPTH OF FT BELOW <br /> GRO[lTSP..ECI(=1GATIONS 0EXPLOSIVESFROM TO FTBELOW$URFACE <br /> TREMIE TYPE TO BE USED {]AUGERS [�HOSE ©PIPE �]MUSHROOM CAP nT(>3 FT) �FT.BELow suRFAce <br /> COM <br /> ME'NTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR' <br /> .INSPECTION'APPOINTMENTS <br /> I hereby certify that I have piepaCed this application and that the work VgilLbe done in accordance with San Joaquin County Ordinances Rules,and.'•::' <br /> Regulations,and all appllcable;CBlifornia laws. <br /> :`: <br /> isf <br /> Signed Title/Company Ski(*wC <br /> : ,Pont Name Te�ra+t. ��fn Date 2! S <br /> :: DEP,4RTMENT USE ONLY j <br /> :. <br /> :SITE MAP.IN UNIT IV.FJ4E-SITE ADDRESS. <br /> WORK PLAN DATED:: .':. r <br /> APPLICATION ACCEPTED,BY J• 1 GII�Kran sum <br /> DATE:I <br /> y <br /> GROUT INSPECTION,OY FINALJNSPECTION BY DATE �7 <br /> DESTRUCTION INSPECTION BY DATE. <br /> CQMMENTS/CONDITIONS: <br /> 777 <br /> ACCOUNTING ONLY.: AID# `•` ::. FAC# <br /> SERVICE RO# <br /> `RE CODES. FE�.fiNFO AMT REMITTEb CHECK# RECV D BY.':" DATE JNVOICE <br /> REQUEST PR# <br /> S 3 0i.c SRS <br /> Z: O $130 x C1 1. :.I <br /> `RO# <br /> I <br /> : ... . <br /> :. . <br /> (3500) <br /> NT Am <br /> `'. <br /> PR <br /> (2sao) <br /> :C7 ✓ WC .'_ WAIVER w{m-. G57 LETTER OF AUTHORIZATION TO.S.IGN PERMIT.: y"' ENCROACHMENT OCy. <br /> •::EHO.29-0]'7124114 WFL1 PERMIT APP <br />