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oaq�I SAN JOAQUIN COUNTY <br /> LOP ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> t FsR�;P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.s' ov.or /eh E � 4 C®CD <br /> WELL & BORING PERMIT APPLICATION 1� <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIOfS EB I 1 2011 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NNi <br /> Application is hereby made to San Joaquln County for a permit to construct and/or install the work described. This application is mAa 1 QAWfiW 'RTH <br /> Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health DepartmeRMIT/SERVICES <br /> Site Location Cross Street City < {tmL an aZip 9S? O� APN l63- 06)0A (4 <br /> Property <br /> Owner R64d RarnI24r Address _1A i7r.34fl''^ tAy4me ke� _ City 616 La CA Zip gc2b6 Phone 2o5 - 'ISI-72A <br /> C-57 ContractorS Address 2 C wJs lionl City ��, y �,. &% Uc Z'4 Phone sib - S90 - Id Taj <br /> ConsultanVSub Cntr C , r/ua riC Address W City . K:ehMM�e( [DLit 799370 Phone 510m3o7- 99N3 <br /> Billable Party _CA: f X. (Olydvb Address _- traA ACity g� `( Zip !j Phone Sl0-, S`I_A,-.109 9 <br /> GIs Coordinates: X1-1 &9313515b Y — 12 L312ZS91e ,for jW -'I-� "' <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> E NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) <br /> ❑ SOIL BORING IDs <br /> [3WELLIDS {y IS 1.0 &A nra n,. 'T1. t_e `9p . <br /> UOTHERl6S t2ch &^ ne5n4s <br /> TYPE & # OF WELLIBORIG INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ' <br /> _❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE LSbZ " El MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: 11 <br /> _D EXTRACTION: Vaporl Water D HAMMERIDRIVEN CASING THICKNESS 0 •rt TYPE OF CASING: N STEEL D PVC D OTHER NIA <br /> _D SOIL VAPOR PROBE D MUD ROTARY DEPTH OF GROUT SEAL A. 1A TREMIE TYPE TO BE USED: D AUGERS D HOSE D PIPE <br /> _D SOIL BORING 9 PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: D Yes D No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —t INJECTION O AIE Soarae ozone I D HAND AUGER J GROUT SPECIFICATIONS W14 <br /> _D OTHER: NIA D OTHER: A/(A APPROX. BORING DEPTH 3J i - ❑ BOLTED TRAFFIC BOX OR ❑ STOVEPIPE <br /> tf CONDUCTOR CASING El [AD Y Casing Dia: �1 /e Casin Depth: /� Ban 04 <br /> COMMENTS: spA' Gg E1dY� '� /=1 NO CAS r�.J6 1r-1r'%WINa fel Di jygSiTT-C>'Q7QN " 1�® J1am N <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE AC S OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DEISTRUCTION METH HECK ALLTHATAPPLY) 000000001 <br /> # OF WELL($) TO BE DESTROYED ❑ VER ORE DIAMETER O N /d INCHES TO DEPTH OF AAAA FT <br /> WELL IDs: ❑ P ESS RE GROUT TO DEP H O��� FT BELOW SURFACE <br /> GROUT SP (CATIONS ❑ E LOST ES FROM TO _FT BELOW SURFACE <br /> T-R€MIE�PE TO-BEUSE - : - UGER5-❑-HOSE-0-IP - -MU RO - -CAP7rrj>3 r F1 BE OWSURFACE <br /> COMMENTS IV <br /> 5 WORKING DAYS NOTIC E D (ALERMIT CE) FOR IN/$ ECTION APPOINTMENTS <br /> I hereby certit t 1 have prepared this a li tion d th tn ordance Sal Joaquin County Ordinances, Rules and <br /> Regulationsa a 1 a able altforni la sSigned I st c aJ•er ry P <br /> Print Name JT a <br /> ateD ONLY <br /> SITE MAP IN UNIT IV FILE - SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BYO <br /> SUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTIO Y DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID # AC # <br /> PE CODES FEE INFO AMT REMITTED CHECK R <br /> RECV•D BY DATE SEREQUEST PR #VICE RO # INVOICE <br /> $ 122 x SR# <br /> RO # <br /> 3500 <br /> PR # <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHO 29.01 07/28/10 WELL PERMIT APP <br />