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houth <br /> SAN JOAQUIN COUNTY <br /> r. ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1� LOP <br /> SITE MITIGATION <br /> 600 East Main Street, Stockton , CA 95202-3029 UNIT IV <br /> � <br /> Telephone: 209) I 468-3454 Fax.' (209) w. <br /> 2091 468-3433 Web: Wwsiaov.ora/ehdREMVED <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION FEB 1 1 2011 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED p�1����,p�(��I <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described. This application is me dAll4:� {X}FebIWNFtALTH <br /> Joaquin County Development Title, Chapter 9-1115.3, and the Standardsofthe San Joaquin County Environmental Health Department. r't MIT/SERVICES <br /> Site Location IR1T5�1111 �iNSho Ar¢ Cross Street LAS, Y/`) V.l City �.. I r? fe ZIP q � o4 APN 1(j (af) — l µ <br /> Property y, "�r��r`rc <br /> Owner �IorN ai Address gm- 5oAfreirhaAya City <Aacle4ain C ZIP 9FZ0Phone Zo9 _ 131_"12R3 <br /> C-57ContractorT,�ti �. Address gy7CT� t1t f CitYa CA Lic 6 7111,6 1 Phone sl0 -Syp . /pg9 <br /> Consultant/Sub Cntr 9,0Ariu 1W6AWL Address Tt9 Tew 11464 AIA o City Lic 61 g931O Phone 4410 - 7`/ YJ* 2 i <br /> Billable Party C\enarvr.4krr qv%vP. Address 7-1_111 FCily _ ncj4y„ ,Q & <br /> t Zip_fal("t ,.Phone SIC '310 \699 <br /> GIS Coordinates: X 11645 Y " ll, 19 25SSYhltj �� <br /> i a19 t28b7 — /21. 31 rt �az_ Sef- 2 <br /> CONSTRUCTION WORK TO BE PERFORMED <br /> NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) <br /> ❑ SOIL BORING IDs <br /> M W ELL IDs <br /> [I OTHER IDs <br /> TYPE &-# OF WEI I /BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _El MONITORING 0 HOLLOW STEM DIA, OF BOREHOLE S r n . ❑ MULTIPLE CASINGS LIMULTI-LEVEL/ WELL CASING DIA; 2=1Y <br /> _❑ EXTRACTION: Vapor) Water ❑ HAMMERIORIVEN CASING THICKNESS -Se 40 TYPE OF CASING: ❑ STEEL N PVC El OTHER <br /> _El SOIL VAPOR PROBE I-] MUD ROTARY DEPTH OF GROUT SEAL ML4 Mtn TREMIE TYPE TO BE USED: *AUGERS El HOSE ❑ PIPE <br /> _❑ SOIL BORING ❑ PUSH POINT (GPI CPT) GROUT SEAL PUMPED: El Yes 1E No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION fi.e .Ak soaroe Ozone) D HAND AUGER -4�._ GROUT SPECIFICATIONS I V�t aoM• 1 '� ror} I nv� ('P .�� C- I0 LU ALF <br /> _O OTHER: &IIp ❑ OTHER: MIA APPROX. BORING DEPTH <br /> ._�' 5- JVBOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br /> COMMENTS: _*4 <br /> CONDUCTOR CASING N No ❑ Yes: Casing Dia: Casing Depth: i\s 14_— Boring Dia: MIA <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD r HK E ALL THAT APPLYI <br /> L <br /> W LL IDs: / <br /> OF WELL(S) 70 BE DESTROYED ❑ OVER-BORE DIAMETER OF&._INCHES TO DEPTH OF & r1A FT <br /> A SDIZETRO DEPTH OF Alit FT BELOW SURFACE <br />_GROUT SPECIFICATIONS —Jy-IRi EXPLOSIVES FROM >J TDET�ELOWsuRFADE <br /> COMMIENTTIFT REUSED-{}AUGERS—�WOSE-❑-PIP USHROCM CAP AT FT)_EL) pt Fr BELOW SURFACE <br /> 5 WORKING DAYS NOTICE RE2tt11RED (AFTER PERMI ISS CE) O NSPECTION APPOO NTMEN S <br /> I hereby that I have prepared this applic �� nd that It or I be one I a orda a San oaquin County Ordinances, Rules and <br /> Regulatio , an 11 applicable Califs a 31 <br /> Signed TNel o pa % K to/ 1 x.. �I u <br /> Print Nam s Date <br /> EPARTMENT SE ONLY i <br /> SITE MA IN UNIT IV FILE - SITE ADORE S <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY FINA SP CTION BY DATE <br /> DESTRUCTION INSPECTION BY D E <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID # FAC # <br /> PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE RO # INVOICE <br /> REQUEST PR # <br /> $ 122x <br /> 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 /> EHD 29-01 07/28/10 <br /> WELL PERMIT APP <br />