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4p•4!!Iff. SAN JOAQUIN COUNTY <br /> �(f'•A <br /> EP6RONMENTAL HEALTH DEPARTdNT LOP <br /> SITE MITIGATION <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> 4a Telephone:(209) 468-3454 Fax: (209) 468-3433 Web:www.siaov.ora/ehd <br /> crFaa <br /> WELL & BORING PERMIT APPLICATION NAI. <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS ANDINI <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDVVVVVV ee'1 <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 Develop ment Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location-48+.1Crass Street PO 4�c'a.D-• A^aNa� City Vjpc, + zip�� APN�f <br /> QA+rdwk-M/¢.N`/F 37��a <br /> Property014 7,4LL Phone <br /> Owner Ih At Ait c o2&oo c+tis Address ( c <br /> OZ" PA •r-w kvgAQJ : City Sd'n t�L�orJ zip <br /> - o �.yy_I>a.•r••� SB 4,WvwkR� City htA9�\�.-Z Lie Gr[GILs PhonekY.c <br /> C57 Contractor Address S <br /> u'ISSS� <br /> Consultant/Sub Cnir L/.A- _ Address 10444takOe GY�BI�I�IOt City *LgAio (,E&"v&Lic Phone 9TF 9k 411 V4 <br /> -57 <br /> Billable Party (ASA- Address 4a.ony City SrFwt� Zip GiS4'?J Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> WELL IDs lk <br /> ❑OTHER IDs <br /> TYPE&#OF W ELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 1 MONITORING El HOLLOW STEM DIA.OF BOREHOLE�_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: Z <br /> ❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TTYPE OF CASING: ❑STEEL ❑PVC [3 OTHER <br /> O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Nf TREMIE TYPE TO BE USED: 9tAUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING O PUSH POINT(GP/CPT) GROUT SEAL PUMPED:ILYes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION( Air Soame Ozones❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: �C <br /> APPROX.BORING DEPTH [!S BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING]$-No[I 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 /> _#OF WELL(S)TD BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: C3 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO SURFACE FT BELOWSURFACE <br /> TREMIE TYPE TO BE USED:El AUGERS [I HOSE E]PIPE El MUSHROOM CAP AT(>3 FT) <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have preps red this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. <br /> Signed / .t/—Yom�""?gy" pp,, Title/Company ftp '�Date !G <br /> IZ— <br /> Print Name '�Ikc.y • <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DAT ISS D`�/a�/`-�_? AREA <br /> GROUT INSPECTION BY FINAL INSPECTION L-Gi DATE <br /> DESTRUCTION INSPF�Z/T��O�N BY DATE <br /> COMMENTS/CONDITIORS` <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST FPR# <br /> $125 x ��5-�• .7 SR#�.�tX/�fp, <br /> 3 3�✓Ft OU c�/D3/ �� 8 00 OOQ'� <br /> PR# <br /> z9oo <br /> r-97 tAlr. \AIGI\/FR RF71 FTTFR IF:Al ITHOP17ATION TO CIr.N PERMIT FNr:R(laf:HMFNT fl(lf` <br />