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• FILE COPY <br /> Q Q- sF? SA JOAQUIN COUNTY <br /> I t E lil.RONME TAL HEALTH DEPARTMENT LOP <br /> -ILls 1 68�Iazvlton Avenue, Stockton, CA 95205-6232 SITE MITIGA ION <br /> +••:'.`•;" <br /> Telephone: UNIT IV <br /> P ( )468.3147 Fax:(209)468-3433 Web;wWwsiaov.orG/ehd <br /> WE_ 1& 6OR NG PERMIT, APPLICATION <br /> FOR WELLS AND B giNGS USED F R CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> N -R F11N AS f P JT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application U hereby made to San Joaquin Cow y or a permit to nslwcl and/or install the work described. This application is made In compliance will San <br /> Joaquin County Development Title,Chapter 9.1 I .3.1 and Ilse Stan ards of the San Joagbin County Environmental Health Department. e <br /> Site Location z2 yS GN^A^-I�c�ros Shell � mw is City/Slatesock ZIp9s$O� APN /4 p--S <br /> Owner <br /> Property <br /> Owner Ad r ssl_ c A <br /> .City/Slate Zip Phone <br /> C-57 Contactor CG +v c Ad r ss olfT'W i <br /> _ Pglw Oa icityistale APc S, Lic C -6Y O Phone 931-44C -8178 <br /> Consulla USub Cntr KOrh A r ss''�q'1 u'' L.,,P.rt. ♦tu <br /> d1{o� I 'City/Stale L,0,A Lic Phone 510— -6300 <br /> GIS Co Party Ad se !City/Slale ZI <br /> GIS Coortlinabe:%AISLI l6A '17.9`Y W! a P Phone <br /> CO TRUCTIO WOR TO BE PERFOR ED: 3 7. ` <br /> EW W��LLLIBORING(CPT,GEOPR08 HYD UNCH,HAND- GER.OTHER) <br /> 11301 BORING IDs 9 ZD (' L L 2 2S B2G gZ� <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE It 0O WELUBORING N TAL ATI TYPE C NST UCTI i SP C ICA IONS <br /> _0 MONITORING ElHOU. SE D OF BOREHOLE.Z.I <br /> t MULTIPLE CASINGS 11 MULTI-LEVEL WELL CASING EVc <br /> _0 EXTRACTION:Vapor/Water ❑H IE CAI IIJG THICKNESS --N�TYPE OF CASING: 13 STEEL STEEL PVC ❑ OTHER <br /> 1_❑SOIL VAPOR PROBE OM ROTA Y� DEPTIi OF GROUT SEAL /�REMIE TYPE TO BE USED: 0 AUGERS 0 DIOSE PIPE <br /> 0 SOIL BORING USN P01 (GP CPT( GRI T SEAL PUMPED:O Yes <br /> BFo(MAXIMUM FREE FALL DEPTH IS De Fn <br /> _I7INJECTION no ursmm ,.. <br /> 0 . ❑HANDA G R GOUT SPECIFICATIONS Vl C0. <br /> _O OTHER: C1 <br /> 2 <br /> ❑OTHER: _AP>ROX.BORING DEPTH I D � O BOLTED TRAFFIC BOX OR <br /> �/ 06TOV PIPE <br /> IO <br /> COMMENTS: CO iDUCTOR CASING no O Yes:Cegng Dia:.Cesing Depth:_Sorina Dia: <br /> NOTE: OFFSITE WELLS&13 RI GS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORM DEBTRUCTION METHoO rcHEc THAT APPLVI <br /> _AOF WELL(S)TO 9E DESTROYED 0OVER-BORE DIAMETER OFTH <br /> iNCHESTOOEPOF FT <br /> WELL IDs <br /> GROUT SPECIFICAT1:1PRESSURE GROUT TO DEPTH OF <br /> IONS 11 EXPLOSIVES FROM FTBELOWSU FACE <br /> TREMIE TYPE TO BE USED:0 AUGERS H BEI PIPE ❑MUSHROOM CAP AT >L3 F 7o FT BELOW SU FACE <br /> COMMENTS n FT BELOW SU FACE <br /> 5 WORKING DAYS NOTICE QUIRE[ (AF�ER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby tertlfy that I have prepared thle appl •allot antl that tl a wo <br /> Regulations,and ark will be done In accordance with San Joaquin County Ordinances,Rul and <br /> Signed ,,,,l[ll appllwblIllornla laws l h <br /> IrJr T Tille/Company a C <br /> Print Nama /-/ it /y r krlA. I <br /> Dale /J <br /> dRTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE•SITE ADDRESS 15EP1-4 P69 ftTEp Wag, �`�a,(•pp� . <br /> WORK PLAN DATED I u 7 zfiI 3 <br /> APPLICATION ACCEPTED BY ; p y✓I <br /> GROUT INSPECTION BY I DATE IS (� <br /> FINAL INSPECTION BY 2 -/j <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: I I <br /> ACCOUNTING ONLY: AID 7/ FAC N j <br /> PE CODES FEE INFO AMT REMITT 0 CHECK a RECVD BY DATE SERVICE RO/ <br /> np REQUEST PR <br /> INYOI E <br /> /.lb2S S125x ! �D41v Pp-!� SRN sQ / <br /> 2CiV J 375 RO p <br /> 3500 <br /> PR N <br /> -57 ✓ WC .i WAIVER !1! p 790D <br /> C <br /> EHDC-5 2e-0t 5/0911257 LETTER OF AUTHORIZATION TO SIGN PERMIT _ ENCROACHMENT DOC d/ <br /> WELL PERMI APP <br /> I <br />