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Lo P <br /> aPA�Iy. <br /> SAN JOAQUIN COUNTY <br /> Z �a ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> ' 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> Telephone: (209) 468-3454 Fax: 209 468-3433 Web:www.s' oY.or lehd UNIT IV <br /> �ilSdr'� ( ) la a <br /> WELL & BORING PERMIT APPLICATION I CE�VED <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIA <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 9� � �'rn1f� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made i�poN comp is <br /> Joaquin County Development Title Ch ter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Dep made <br /> F#i /� &IYLctf-k0-1�.7 <br /> Site Location //,y9p tom' ,MFProperty ,( 115-Across Street %�/iS9- n2ir City L _t*�Zip qq�-'�nn ENVIRONMENTAL <br /> owner1&Ijuz7f �C1Fmy* Address 1216 ic*05H1C10 LT'l- City- p2'fr Zip <br /> 157- ,7(2 Phtirtl p3ZF7�'l<�"z <br /> C-57 Contractor WDC_ Vj., ) Address 147/1 ,tNErjKv7 City t/Cw.1�A_�'Lic, jC Phone <br /> ConsulfanUSubC�ntr hL Fi/A//,26Ngddress u N• /�//C City�r is�0�Phone 1&2-72:"707 <br /> Billable Party RLA" 6A/✓17LC?! Address L7f"/ 3� City ( [ Zip �SDpi Phone /rir12-72.1-o ?i j <br /> GIS Coordinates:X--A2--42-L2 Y — "h 3 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> [I SOIL BORING Ips <br /> WELL IDs (! <br /> OTHER IDs 1 <br /> ���aaa .TYPPE,,, &#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �A <br /> MONITORING ]ii HOLLOW STEM DIA.OF BOREHOLE _I d/1 ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA V <br /> _0 EXTRACTION:Vaporl Water 0 HAMMER/DRIVEN CASING THICKNESS 1 P TYPE OF CASING: 0 STEEL CKPVC 0 OTHER <br /> _❑SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL iid,, TREMIE TYPE TO BE USED: 0 AUGERS ❑HOSE 0 PIPE <br /> t-0 SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes IP No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION(i a A,Soame Oz,I 0 HAND AUGER GROUT SPECIFICATIONS <br /> _O OTHER: 0 OTHER: APPROX.BORING DEPTH 1 '®BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING II No 0 Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: 9W4&r:9;/V12�-TGIF DE1d1Yy-Cay7✓6I-e L P AN r;' �'W&L .y&j -If Wa Z-') <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> D 0TRUCTION WORK TO BE PERFORMED: DESTRUCTION M THOD: CHECK ALL THAT APPLY <br /> OF WELL )TO BE DESTROYED ®OVER-BORE DIAMETER OF 10 INCHES TO DEPTH OF195FT <br /> WELL IDs: O PRESSURE GROUT TO DEPTH OF FTSELOWSURFACE <br /> GROUT SPECIFICATIONS - ❑EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE 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 /> 1 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 /> Regulations,and yl applicabl alifornia Laws. <br /> Signed IT1A�fVl Title/Company <br /> Print Name —� Date rzo <br /> ��(� / y�D� DEPARTMENT USE ONLY LO�� <br /> SITE�vMPTN UN1Tl Eb1TEADDRESS <br /> )NbRK PLAt <br /> A. ®.TIO ACC DATI ISSUED 7- S /?i AREA <br /> SPECTI N BY FINAL INSP,E�CTIION�BY �� DATE <br /> DESTRUCTION INSPE TION DATE <br /> ya(/�/� <br /> � MMENTSICON DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# <br /> REQUEST PRg# <br /> INVOICE <br /> $125. L CCe SR# Qb3 <br /> R°a5 Is /3 <br /> <%- W 9�V 'f WAIVER C57 LETTER OF AUTHORIZATION TO SIGN ERMIT ENCROACHMENT DOC <br /> ��I�� 5i2.eG�53�3,e i. <br />