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IVA,& <br /> miEC""'t"' <br /> SAN JOAQUIN COUNTY A 0 6 2 j i10 P <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029N <br /> ENVIRONME A 1 <br /> Telephone: (209) 468-3454 Fax.- (2.09) 468-3433 Web:www.sjqov.orC0MAIT1SERViCES <br /> WELL & BORING P'ERMIT A"PPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit 10 construct and/or install the Work described. This application is made in compliance with San <br /> Joaquin nly Develo ent Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> ;C�l U <br /> 51r),j+1-LS &I-aajk rip <br /> Nall <br /> Site Loc A0,AA3TCrossStreet G.r& ^T5 _- <br /> City sfO C-k'rO It Zip' 95 2 APN: 4311'Z 7 <br /> Property II <br /> OwnerAddress I 5. City 5'i&Ck1_oj Zip J5206 Phone 20 � -8(4f <br /> C-57 Contractor Pre 4 i'j jo^ Address PC- CityIt til Lic 634397 Phonel-MI)LI65-9712- <br /> ConsultantISubCntr-CaAjor-,r.-14 Address 188 City '57-qc47-&q Lic 7 3 71 o 66 Phone isq)7-31-0518 <br /> Billable Party C 0,110 1 6*,,.1 1_� Address Cit' -1'_t0-CkfAj Zip OJ_5-to 6 Phone2e4) _jfn <br /> City <br /> GIS Coordinates:X 633,63U, y 1-17)q7O <br /> CONSTRUCTION WORKTO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs FILE COPY <br /> �WELL IDs IVJ <br /> F-I OTHER IDS <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _LffMONITORINGI <br /> RkLLOW STEM DIA.OF BOREHOLE __�o L01Ej MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _D EXTRACTION:Vaporl Water 0 HAMMER/DRIVEN CASING THICKNESS 51*4 J7 TYPE OF CASING: El STEEL KPVC 0 OTHER <br /> _tD SOIL VAPOR PROBE [I MUD ROTARY DEPTH OF GROUT SEALS,.-7-3 TREMIE TYPE TO BE USED: El AUGERS E)HOSE Pk PIPE <br /> _Ej SOIL BORING D PUSH POINT(GP./CPT) GROUT SEAL PUMPED:[3 Yes K No(MAXIMUM FREE:FALL DEPTH IS 30 FT) <br /> —0 INJECTION 6 e.Air Sparge.Ozore)C]HAND AUGER GROUT SPECIFICATIONS -f- <br /> _[I OTHER: 0 OTHER: APPROX BORING DEPTH BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING p5No❑Yes:Casing Dia:_Casing Depth:_ Boring Dia:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY <br /> #OFWELLS)TOBE DESTROYEo:: 0 OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: El PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS El EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:Ej AUGERS [_1 HOSE El'PIPE ❑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 Cotrnty Ordinances, Rules and <br /> Regulations,and all applicable California laws. <br /> Signed <br /> Print Name LV�_ Date <br /> -.DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS U L2 e-.Z S1 4e-,' 15.�_6 <br /> WORK PLAN DATED <br /> A u &5 <br /> APPLICATION ACCEPTED BY Vi C±o ri...q Mo,_L"a,rta g!:a DATE ISSUED 4-- 7- /Z AREA 145 <br /> GROUT INSPECTION BY V j t±n&L,=q -j FINAL INSPECTION BY V'16b-r�A_ DATE 4-M-11 <br /> DESTRUCTION INSPECTION BY t DATE <br /> COMM ENTWCOND ITI ONS: -EY2-1-4 MW -7 <br /> ACCOUNTING ONLY: AID'# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> REQUEST PR# <br /> 67D 1 $122X /2Z 7 SR# 00i 22 72 <br /> RO# <br /> (3500) <br /> PR# <br /> (2900) <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 0-7128110 WELL'P�ERMITAPP <br />