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AOP C (D MED <br /> >• •.. a kip SAN JOAQUIN COUNTY <br /> Z /�w;^f ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> • 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> :P Telephone:(209) 468-3454 Fax: (209) 468-3433 Web:www.sioov.orcl/ehil UNIT IV <br /> •ikon' <br /> WELL & BORING PERMIT APPLICATION R D <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIA CC'VCC <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 2 T, •�r�/' <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applies tion is made i��cotmp6afke5dttKZan <br /> Joaquin County Development Title Ch ter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> FVr�2 L'tKctgfc (tl <br /> Site Location 1/ rJ40 C^rNF,(ND@EACross Street L"Visr- 40FAA'r city �*t.hip ENVIRONMENTAL HFptn, <br /> Property C=�q�" <br /> Owner /(Mq/ZV�r lCN7ANA Address l7/(� /cA6�N2/O xj_ c;ty. _ U Zip QS3 phone '3Z�7�i�z <br /> C-57 Contractor /.SDG IVfJ Address GI #HarC <br /> ( fes- 9 �,.J City iC/�%lsA�!'Lie Phone <br /> Consultant/Sub Cntr&r��f�� N`Address j4-rT/"• 5•%x'7/6' city x,/f-�L;c�fj, phone_{02�711��fi 707 <br /> Billable Party e " tZ/V✓//u� Address jr �3 city rd?Wl ZiP AD jC-S 'Z� <br /> Phone `ppZ-7 `C 7f <br /> GIS Coordinates:X_3'1Q is Y�" I <br /> CONSTRUCTION WORK TOO BTE PERFORMED, <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> WELL IDs <br /> OTHERIDS t <br /> -wwTYPEE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 19 HOLLOW STEM DIA.OF BOREHOLE -jbl� 0 MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> _C]EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS go, TYPE OF CASING: ❑STEEL IX•PVC O OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL L r TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> 1-0 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED ❑Yes III No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _I]INJECTION(I,Air Spam Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> OTHER: ❑OTHER: APPROX.BORING DEPTH 2 5-1 - 1B BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING 13 No❑Yes:Casing Dia: Casing Depth: Boring Dia:_ <br /> COMMENTS: -RGf1( NTd rC WAF4j c [.DF1dM.t/CJZp7✓Q -"ej&> 4fsrj AVW A2(A,f_ M4V -f 4My N{W <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS r <br /> D STRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THATAPPLY! <br /> y� OF WELL )TO BE DESTROYED 90 OVER-BORE DIAMETER OF IQ INCHES TO DEPTH OF �FT <br /> L IDS: r^ A r^ ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Al I/ t- ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:AAUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) <br /> COMMENTS FT BELOW SURFACE <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 I appli bl alifomis Laws. <br /> Signed A_�'tl Title/Company "- <br /> - r. <br /> Print Name :,*I l .L Date/ Z• <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS �V <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED B DATE ISSUED 2 g /Z AREA oto P <br /> GROUT INSPECTION BV FINAL INSPECTION BY �� DATE <br /> B <br /> DESTRUCTION INSPECTIONDATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> LFEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# IN <br /> REQUEST PR# <br /> $ 125X2. 2,50. /o86Cf i s ,z sR#pb 3 <br /> IK 375 . /D9 7 G RD0 I3Sit 59o)l,69'3 3dW WAIVER C57 LETTER OF AUTHORIZATION TO SIGN ERMIT _ NCR,�CF{yr1EN,j,DOC <br />