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... SAN JOAQUIN COUNTY <br /> FILE COPY <br /> ,coG LOP <br /> IF ? ENVIRONMENTAL HEALTH DEPARTMENT <br /> lidK SITE MITIGATION <br /> : <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> j/ hone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br /> v WELL & BORING PERMIT APPLICATION <br /> AUG 1 7 tM WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I� I O.IVNry Iv 'V <br /> ' <br /> gNP�� WW�l►►I�� r oaquin County for a permit to constmd and/or install the work described. This application is made in compliance with San <br /> aSgdl5Nt - e, Chapter &1115.3, and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location /1SS0 GfSH 1 nt CE cross Street AN6C7'0r/ aykb City 4%b0gb" zip Z.CoA / 9 APN 07/ 1'700{ <br /> Property <br /> owner AdCCAAA710 + eLS_r_§4Address1tAjS . ELAc.(abO s7, city s:bCKT6r4� zip94:269 Phone74/G 4675 <br /> C-57 Contractor l2 S..T Address AO0 N . EAST s' % City W Oo'y C Li 0273 Phone 53066JZ (/Ly <br /> Consultant/Sub Cntr Arc Address Nl7 LONE PAwf AVC city Mal do Tb Lic Phone s74 C2Z <br /> Billable Party Address city zip Phone <br /> GIS Coordinates: X . 055 Y <br /> CONRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING. (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) <br /> ❑ SOIL BORING IDs <br /> ❑ WELL IDs 0 S y OSZ OS <br /> ❑ OTHER IDs •\ <br /> TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑ MONITORING OHOLLOW STEM DIA. OF BOREHOLE St ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: y rY w <br /> _I] EXTRACTION: Vapor/ Water ❑ HAMMERIDRIVEN CASING THICKNESS orrIli . TYPE OF CASING: ❑ STEEL R'PVC ❑ OTHER Q <br /> _❑ SOIL VAPOR PROBE [I MUD ROTARY DEPTH OF GROUT SEAL �TREMIE TYPE TO BE USED: I] AUGERS El HOSE EI PIPE <br /> —E] SOIL BORING [I PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes (MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> �p�INJECTION Le .Air Szone FI HAND AUGER GROUT SPECIFICATIONS CC4�40N�A A 3a # E 36^•7auITE <br /> ❑ OTHER: El OTHER: LT <br /> OTHER: APPROX. BORING DEPTH >gr " r BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br /> CONDUCTOR Cy�SIN� [ o ] Yes: Casing Dia: Casing Depth: Boring Dia:_ <br /> COMMENTS: SEE ATG 4JOAKPOL" ',14 •/fD 3/S//O <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> _# OF WELL(S). TO BE DESTROYED ❑ OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDS: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT L3 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 thi pp ration and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations, aDd all a/pp To Califo b!a I y� <br /> Title/Company .e f doL •o/'li i A7<= /¢S5bel#47 <br /> Print Name /o Del e i✓C/L Date g311 /O <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE - SITE ADDRESS <br /> WORK PLAN DATED '3 � 5'10 �� <br /> APPLICATION ACCEPTED DAI E ISSUED AREA <br /> GROUT INSPECTION BY - f EM FINAL INSPECTION BY " -Y f r DATEg •-27 -/ U <br /> DESTRUCTION INSPECTION BY DATE a <br /> _ <br /> COMMENTSICONDITIONS: :512 i - - z <br /> ACCOUNTING ONLY: AID # FAC # <br /> PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BYDATE SERVICE RO # INVOICE <br /> REQUEST PR # <br /> 5Q1 $ 122x 3 3 �� . SR# 0060"1qY <br /> 3 6 RO # <br /> 3500 <br /> PR # <br /> 2900 <br /> EC-57 V <br /> HD 29-01 07/28110C WAIVER C-57 LETTER OF AUTHORIZATIONFilEN2Ml4 FF DOC <br /> ERMITAPP <br />