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. . <br /> Nauln, • SAN .IOAQUIN COUNTY ,REQ <br /> ENVIRONMENTAL HEALTH DEPARTMENT Zp <br /> 1868 East Hazelton Avenue, Stockton, CA 9522 MI IGATION <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:wwws WH <br /> IC IV <br /> WELL & BORING PERMIT APPLICATION ICES <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 to construct and/or Install the work described. This application is made in compliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> S lte Location J08 (A6!;1 cm5 am(may Cross Street UM Coll) ,S-i p[-t y Zip I ,r'20(_o ApN I(Q5t�Ufl1�p <br /> Property Cit 3t (X-tTo%� < <br /> Owner C1V-jr?zJ Address ( (OI Hotl✓�cf�atYa SAy (�Aot) �(If593 �oS) 34?-(mD <br /> R11Y Zip Phone <br /> C-57Contractor Address SDo ('lWth1 ST. City Wi­)�D6LRND LIDJ Phone(�3a) yIG' ZI17- <br /> Consultant/SubCntr ✓-Ib4tfL Address -601410(C,0Pz (E�6 \ CityRAwttDcco�pVH{icPhone�l���(AI-040L'� <br /> SZb <br /> Billable Party ��-RAJ�C'L Address 301 ' I:ILUOp�; city>QA� 7&E�w/1 Zip phoneLgl(g� E(n( -0400 <br /> GIS Coordinates:X 3}q3 Y `121,29 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ri]NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,(4HER) el NLi.�tPcT O/.) <br /> ❑SOIL BORING IDs <br /> DWELL IDs - N `$- I ZXANcR UC 2 -I-1.1� VC fo E <br /> ❑ OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS (- <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE1�i,11 ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 5 ErEXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS O.I54'Q 23}TYPE OF CASING: ❑STEEL VLPVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL\I AeyC} TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE 4.PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED: Yes ❑No(MAXIMUM FR FALL DEPTH IS 30 F7 <br /> I�[3-INJECTION Q.e Air SP,me,Otonel❑HAND AUGER GROUT SPECIFICATIONS Al <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH UZr tC 'P.M I(,-\{ypFp BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING No Yea:Casing Dia: Casing Depth:_ Boring Dia: <br /> COMMENTS:S vnpyr evkr w� ] �rol(� �UC--2ia.ry T <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLYI <br /> #OF WELL(S)TO BE DESTROYED - ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: [3 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO <br /> TREMIE TYPE TO BE USED:E]AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT LF7 BELOW SURFACE <br /> 3 FT) T BELOBELOW 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 /> Regulatlons,and�Il/ap/pJica/bJ�ejalit rnia Laws. 1 1 ��� �/:' <br /> Signed _ `'%.n A� `1'Y �T� t-z Title/Company �NI� GCQCZICW( ,*"A EG <br /> Print Name _ 1 V\V'tK•� )� lS `N\�C:- Date Q' - <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE <br /> �ADDRESS / W.4,1 <br /> r <br /> WORK PLAN DATED My+1 �,[il 2-0II 4 •a+vC- /9/?0 /Z <br /> APPLICATION ACCEPTED BY J. y0>q(Lt- DATE ISSUED /0 -•2-r 2- AREA /LQL( <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM E N TS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED !CHECK# RECV'D BY DATE SERVICERO# INVOICE <br /> REQUEST PR#G191 s125 X / /87S 721 9 q do«K)T-rk �--2'-/2 SR# 6562 y <br /> RO# <br /> (3500) <br /> PR# <br /> (2900) <br /> C-57 WC / WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT d ENCROACHMENT DOC—A/2— <br />