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P, - FILE COPY <br /> D SAN .IOAQUIN COUNTY ~ <br /> ^"r ` w�/• ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> cyi ' _ �""" SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:www.sioov.ora/ehd <br /> WELL & BORING PERMIT APPLICATIONCEIVED <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMED A <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 2 �� 77�/If' <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made JAN compi"afke44flh'san <br /> Joaquin County Development Title C.h�pter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> F '1jV4* - viric.lFIcJLI a7 17g. t . ENVIRONMENTALH <br /> Site Location J 1,4 0 CAM0" F, Cross Street t.8t/ SX �1�� City 1� 1W+YZip <br /> Property t� s -3432. <br /> Owner A�tA2ulr kk?Ams} Address /7/� IGAro�zN/z10 LYZ- City Zip_(j lt2 hone <br /> C-57 Contractor /.:DC- r y�Lek& T[G Address � 'i A/1 <,9 City 9k iL�!r_(gw.!�"Lie 2k�STz6 Phone <br /> Consultant/Sub Cntrb-Ir r_�-_ .0.Fi�AI//RBN Address f!�jr3w X7/,6' City PA-t �/k� jc�J-Phone 6'eZ-74"'707 <br /> Re <br /> Billable Partyj 4f4 FLAN,✓I/U'?4 Address I�e /t/ 3� City J?dngk(k Zip j:STJCb Phone 4+02 77V-`C 707 <br /> GIS Coordinates:X V-424--x1 5 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> %Q NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> WELL IDst 6' <br /> OTHER IDs <br /> C. <br /> .^ ' <br /> TYPE&#OF WELLlBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS A <br /> 41111" MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE ElMULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA'. _ V <br /> _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS P TYPE OF CASING: 0 STEEL CWPVC O OTHER <br /> _❑SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL /.e, TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> V-0 SOIL BORING 0 PUSH POINT(GPI CPT) GROUT SEAL PUMPED 0 Yes Ij No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ❑INJECTION(e Air Soeme.Ozone)0 HAND AUGER GROUT SPECIFICATIONS <br /> _O OTHER: 0 OTHER: APPROX BORING DEPTH Sr JN BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING IS No 0 Yes.Casing Dia: Casing Depth: Boring Die:_ <br /> COMMENTS: 2WUcrv�r F Lt1lF.I,Gc CDF4T2VyLy/v ��l�D ApD, Nir4y pvLL M&,-I A•/'7�N[W`Z� <br /> NOTE: OFFSITE WELLS 8 BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> D STRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> OF WELL )TO BE DESTROYED ®OVER-BORE DIAMETER OF 11INCHES TO DEPTH OF FT <br /> VVELLIDs: '- I - ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS / L ❑EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERS ❑ HOSE ❑PIPE [I MUSHROOM CAP AT(?3 FT) FT 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 /> Regulations,and <br /> ia Laws. <br /> Signed <br /> Title/Company <br /> Print Name _ 1�_IiL4:M Date/ <br /> �T DEPARTMENT USE ONLY // <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS /(0 <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE ISSUED 2 g /Z AREA al l <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> c� <br /> /�Q/ REQUEST PR# <br /> 501 <br /> $125, 2 LSbe /V�71Oq / s /2 SR# Q63 <br /> 3503 '�IK 3?S • /Oq 7 (3°o /3 g <br /> C- W Mee MR <br /> WAIVER 57 LETTER OF AUTHORIZATION TO SIGN ERMIT NC OC <br /> S <br />