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t� rnpX - <br /> n = SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 East Hazetton Avenue,Stockton,CA 95205-6232 SITE MITIGATION <br /> . Telephone:(209)468-M4 Fax:(209)468-3433 Web:www.Bioov.orD/ehd UNIT IV <br /> WELL& BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT FXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for B permit to construct and/or Instal the vark described. This applk rtkn Is made In compliance whh San <br /> Joaquln County Development TIN,Chapter 9-1115.3,and the <br /> +Standards of the San Joaquln County Environmental Health Department <br /> 91b Location 32550 w LIr9YTI1AtECross Street J (RMW1lf5. �. CRY T-" 95304 APN <br /> Owner— <br /> l %Vf'Vx 2l��Pnane <br /> Droner �Ps�rro WhdtSAl.� Address 9qq I.v-ice, Dn�'C. City S5A p 986 <br /> Cm Conlnetor n Ili Address 1641 (,hA(IM13L�riV'[ City fo JL(,ord Lk O RZ elvers 925-8y9^69�� <br /> Consullard/Suh Crdr I Address 2 A&&'j%ctSD City Irvwle Lie Phone 949 727-LIY66 <br /> BIYde Partyr 'Adelase —.� A.An ��7Sb City lryLv.[ Zip. 9261fY Phone 9L Bi -42 -!lf"I <br /> GIS CoordInaW:X Y <br /> rnMSTRUCTION WORK cFOR MED: <br /> GEUIV7ECPT EOPF11HYDRopuHCH,HANO-AUGER,OTHER) <br /> (X�SOI LBORING IDS �-1 <br /> D WELLI <br /> D OTHER <br /> TYPE 6 e OF WEL.LIBORING INSTALLATION TYPE CONSTRUCTION SPE^ CIFICATIONS <br /> _p MONITORING D HOLLOW STEM DIA OF BOREHOLE�rI <br /> 1D MULTIPLE C INGS O MULTI{E WELL CAZNG DIA NA <br /> n EXTRACTION:Vapid Wdw D HAMA£RLDRIVEN CASING THICKNESS ?JA TYPE OF CASING:O STEEL D PVC O OTHER <br /> —nSOILVAPORRIOBE OMUD ROTARY DEPTH OF GROUT SEAL O -9 RTRENE TYPE TO BE USED:D AUGERS IJ HOSE D PIPE <br /> _AOSOIL BORING /'PUSH POINT(GPI CPT) GROUr SEAL PUMPED:0 Y.CTW(MA'IMUM FREE FALL DEPTH IS 30 FT) <br /> n IWECTION Ba2tMaaa.ID 13 HAND AUGER GROUT SPECIFICATIONS_UetA le <br /> 0 OTHER: DOTIER� APPROX.BORING DEPTH 61 DBOLTEDTRAFFICBOX OR ❑STOVEPIPE <br /> CONDUCTOR CASING SrNo D Yac CwWV Ota:_Cadn6 Dpi,:_Borne Dir <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> nF13TR CTION WORK TO BE PERFORMED_: nESTRUCTION <br /> NOFWELL(S)TORE DESTROYED OVER-BORE DIAMETER OF_JNDHF;TQPEPTHOf FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FTBEI SURFACE <br /> GROUT SPECIFICATIONSD EXPLOSIVES FROM io FTeaow SlatFAGE <br /> TREMIE TYPE TO BE USED:0 AUGERS CI HOSE LI PIPE ❑MUSHROOM CAP AT L'3 FT) FT SELCWSURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I lwr*W uruly that/ha W d Ihla appllwllon and thettho corkwill We dome m aecordsm o with San Joaquin County Ordinances,Rules antl <br /> Repulatlarm,and all a I N Ila Laara r� ' <br /> gp� TILWCompmty �N-SLT(1 I C'nIWTIPv It^M'.'{,:Tr-2_ <br /> PHnt Name 1 ('FFR``r 3A 7� Date <br /> MENTUSE NLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS 3z 7�U �e� &QA61/.Idt< D <br /> WORK PLAN DATED 4?I Zo 1 3 <br /> APPLICATION ACCEPTED BY J.tf O 0 L4 k-1 DATE 155 iww _ <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE ti-ft-13 <br /> DESTRUCTION INSPECTION BY DATE <br /> CORM ENTSfCONDITIONS: <br /> ACCOUNTINGONLY: AID FACa <br /> PE CODES FEEINFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE ROa INVOICE <br /> REQUEST PRe <br /> ;LCf(D5 9125. ROO <br /> (3500) <br /> I sRk 902 <br /> PRI{ <br /> 2900 <br /> C57_/�YJC V WAIVER^r w- C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />