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YrVIEf <br /> SAN JOAQUIN COUNTY <br /> Ee <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> 600 East Main Street Stockton CA 95202-3029 UNIT IV <br /> Tele.,p/�one: (209) 468-3454 Fax: (209) 468-3433 Web: WWW.s' ov.or <br /> I Lj) <br /> t �1�LL & BORING PERMIT APPLICATION ��j r'��ED <br /> � �1 1 BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> PSR StB NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED VT 2 2 2010 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application r�tlorn4ed@n��vpi,F��San�H <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health De V IVi`ICrV r <br /> q RMIT/SE U CE <br /> Site Location 'M I Fs — Cross Street l Q ,� � City _Zip -15J-J APN <br /> Property c c��l,� t— `n _7 <br /> Owner_.�Crcv M JJ'I- Address J �� 1" u7� tf_ City Un\A Zip S��l Phone w tl��pl�� <br /> C-57 Contractor G fD 1-4 ItiM Address 1238 ,41-ce S,1" City W'vdJ! Lic �9�y $ Phone .3f� 4ckl T/9B <br /> Consultant/Sub Cntr Aex i tV0k 6 Address I I61*1A 1'y,nVca 1Ju, City 6U\ l xr Lic_/ Dj a 1 Phone( _01 71 <br /> Billable Party Address City Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEO ROBE,HYDROPUNCH,H NPP-AUGE Or R) A<< r <br /> (XSOILBORINGIDs V� ,'VP–IT, .- 4 ���"c l�t9rill \vr(1 <br /> ❑WELL IDs <br /> ❑OTHERIDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �1J <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: �1 <br /> _❑EXTRACTIOM Vapor/Water ElHAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ElSTEEL ElPVC ElOTHER <br /> _9?``OIL VAPOR PROBE El MUD ROTARY DEPTH OF GROUT SEAL - W TREMIE TYPE TO BE USED: El AUGERS [I HOSE El PIPE <br /> _❑SOIL BORING 1?F'USH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM <br /> ""FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS T\,01— (►�h C(A"_w- r ( n <br /> _E1 OTHER: ❑OTHER: APPROX.BORING DEPTH I _ +'U V ❑BOLTED TRAFFIC BOX OR [-]STOVEPIPE <br /> v 1 <br /> COMMENTS: No <br /> CONDUCTOR CASING 1 ❑Yes:Casing Dia: Casing Depth: Boring Dia: <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 E]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 County Ordinances, Rules and <br /> Regulations,and all applicable Califor ' s. <br /> Signed _ Title/Company 31& <br /> Print Name Date�_V <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE A DRESS 54(9 r F 5tree–(- <br /> WORK PLAN DATED /V�'/9 <br /> APPLICATION ACCEPTED BY C/4 DATE ISSUED 1 /9 // —AREA—/f-';.-? <br /> GROUT INSPECTION BY AAI A( FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: Ty%ir,,f 0t VP- 114 — I <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 3Sos $122x 1 x(30 `/'� C'NT/r' SR# 00AD$ <br /> 3vo33GG <br /> Sr gr Ro# 0 <br /> 3500365 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 WELL PERMIT APP <br />