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.is............................. ........... <br /> FILE COPY ; <br /> Quit SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton, CA 95205.6232 UNIT IV <br /> Telephone:(209)468-3147 Fax(209)468-3433 Web:www.slqov.orcI/ehc1 <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES I 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 Title,Chapter 9-1116.3.and Ilia Standards of the San Joaquin County Environmental Health Department. <br /> Site Location ZOO ILI• Cross Street WnJh11L)III,-) City/Stale 5Vo,k40,i Zip CIS*7/.5 APN )r-)3-'-'10-0 <br /> Property <br /> Owner Sfix Address 11AI)ILYne Cdllwlic fate 6�9,11ot& Zip 'Z�Z-�-4 Phone -704-1- &)9 <br /> C-57Contractor Address 3WO D4."A b S­?mA- citylstateWis+&c', U,65j"'I'a;10 Phone q16- 639-116q <br /> Fn9 Uc_ <br /> ConsultanUSub Cntr Dod-p Address City/State r� Phone. <br /> Billable Party D"o?k Address Eos- 3" -Ia- City/State )f7l/(MMIJ ZiPq?6Lf Phone <br /> GIS Coordinates:X <br /> 2a <br /> Il I V Y21?' <br /> �4. (� M- <br /> 1j� <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> U-NEW WELL/BORING(CPT,GEOP� K,HAND-AUGER.OTHER) <br /> _ <br /> ERSOILSORING D$ I <br /> OWELLIDs <br /> 0 OTHER IDs <br /> TYPE&#OFWELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _E3 MONITORING 0 HOLLOW STEM DIA,OFBOREHOLE e (j MULTIPLE CASINGS[3 MULTI-LEVEL WELL CASING DIA:— <br /> _I EXTRACTION:Vapor]Water O HAMMERIDRIVEN CASING THICKNESS _TYPE OF CASING: 0 STEEL E3 PVC [I OTHER— <br /> _Cj SOIL VAPOR PROBE O MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> SOIL BORING 0 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes C]No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION Ila M 50910 osono 0 HAND AUGER_GIRDUT SPECIFICATIONS <br /> _O OTHER:— 19 OTHER, SONIC, APPROX.BORING DEPTH 120 Fe,j 0 BOLTED TRAFFIC BOX OR a STOVE PIPE <br /> CONDU Rf�S Ilia: ' j() pjft Boring Ol.: <br /> TL "rG&ff6Y <br /> 'y4CI�fg ( _Casing <br /> COMMENTS Llz"'�C ') <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OFWELUS)TOSE DESTROYED DOVER-BORE DIAMETER OF INCHES TO DEPTH OF Fir <br /> WELL IDS: 0 PRESSURE GROUT TO DEPTH OF IFIQ FT BELOW SURFACE <br /> GROUT SPECIFICATIONS C]EXPLOSIVES FROM TO_ -FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:0 AUGERS []HOSE 0 PIPE Lj MUSHROOM CAP AT(>3 FT) ..........!:T 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 split c Ion and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all a I <br /> Signed TitletCompany Fk:\e A <br /> - --SkA'k sku II —Date <br /> Print Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 0 8110 J. A <br /> WORK PLAN DATED 14 "'.2 <br /> APPLICATION ACCEPTED BY J-�,o Kk el DATE IS <br /> GROUT INSPECTION BY FINAL INSPECTION BY nATF <br /> DESTRUCTION INSPECTION BY DATE <br /> COM MENTSICONDITIONS! <br /> ACCOUNTING ONLY: ;ID# FAC 9 <br /> DECODES FEE INFO AMT REMITTED CHECK# RIzCV'D BY DATE SERVICE I# INVOICE <br /> REQUEST I PR# <br /> S125x 5�77 &VtVr4K SRN (0920�� <br /> RO# <br /> 2q6b 175 (3500) <br /> PR# <br /> (2900) <br /> C-57 L, WC WAIVER PU C57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOC IV#4 <br /> EHO 29-01 6109112 WELL PERMIT APP <br />