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SAN JOAQUIN COUNTY � <br /> ENVIRONMENTAL.HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> 600 East Main Street, Stockton,CA 95202-3029 UNIT IV <br /> Telephone:(209) 468-34'54 Fax:(20'9) 468-3433 INeb:wwws' ov. <br /> ct oR <br /> WELL & BORING PERMIT APPLICATION � L <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REM } ITNe. _Ulu <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR PROM DATE ISSUE q r, <br /> Application Is hereby made to:San Joaquin County for a permit to construct and/or install the work described. This applicat► i co p f tvitaan <br /> Joaquin County Development Title,Chapter 9-1'115.3,and the Standards of the.San Joaquin CountyEnv.lronmentaf Heafffh,l�tD�,p� j{.�Lti✓1GvE <br /> Sita Location. 6"a-I: <br /> eSross Street b 11 y ,Oy,;�c City (r� f`l Zip 75 APN Pi -S <br /> Property Ew.:I-k S'•r•�•sdi cljylxry>' Y <br /> Owner'Ta1.1,lPvwrki,wjlai+ Address 7 T!r t r erre- 4 , City /fit h Zip. 4 5' Phone SQ�-?J 'Y V <br /> C-57Contractgr IF& 'A'. Address 1110 Afo-;r" A-k fitrt cit y JL'�+wrlia c'741f�.8 Phone <br /> Corisuitant/Sub�C�"n'tr f Tt hSSolit ddress I J L� G1 A/- sit'. Crty/"�i�(i�a Lie �` Phone PL �`� <br /> BiilableParty Tk tyj4at&4y- (0. Address _715' a,,., City ✓wfaviAf Zipjfill Phone747-t}y9-.:51YI <br /> GIS Coordinates:X Y ( p <br /> CONSTRUCTIONW00KTio BE PERFdRMl�D: <br /> TlEliu.WELL1B.t IRING(CPT,GEQPR08E;}1YDROPIlNGHH4 D A GE ,OT.HER) <br /> `SOfL BORING tbs <br /> I]MLL IDs <br /> D OTHER.ibs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION.SPECIFICATIONS <br /> _O MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE��0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA' <br /> _O EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS J11 TYPE OF CASING: O STEEL 0 PVC 0,OTHER <br /> _❑SO.iL VAPOR 0ROBE 0 MUD ROTARY DEPTH OF GROUT SEAL A14 _TREMIE TYPE TO BE USED: 0 AUGERS ❑HOSE 0 PIPE <br /> �.SOIt BORING ••PUSH POINT jf CPT) GROUT SEAL PUMPED:0 Yes <br /> No(MAXIMUM FREE FALL DEPTH I$30 FT) <br /> —Q1NJEGTIONtl_e.Pksoame.ozone)0HAND AUGER, .GROUTSPECIFICATIONS /Ai4 &w,*14 <br /> _ Q OTHER; ❑OTHER. APPROX.BORING DEPTH. b -64k 0 BOLTED TRAFFIC BOX OR d STOVE <br /> ) g � PIP <br /> E <br /> CONDUCTOR CASING 14 N0 Yes:Casing pia: Alh Casing.Deh�" 80AngDia:Iy''COMMENT&: t" hC , <br /> NOTE: OFFSITE WELI-S& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTfON METHOD.ICHECKALLTHATAPPLY) <br /> OF WELL(s)To BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT `S <br /> WELL IDs: D:PRESSURE GROUT* To DEPTH•OF FT BELOW SURFACE � <br /> GROUT SPECIFlrATfONS. E EXPLOSIVES FRoM O. FT eELOW:SURFACE <br /> TRE'MIE TYPE TO BE USED:.❑AUGERS E HOSE E PIPE ❑MUSHROOM CAP AT(?3 FT) ET BELOW SURFACE <br /> COMMENTS <br /> b WORKING DAY8,NOTk% RSQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENT$ <br /> I hereby certify that i hav9 prepared this aplfltcatlon and that the work will be done in.:adcordance With San JAagtlin County Ordinances,Rules and <br /> Re&Iatlons;. q ail cable i'r hfo i <br /> Signed Q — <br /> Title/Company 41( An'`Ctti44yy' 2-H C S , <br /> Print.Name AL&4o v, A. <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE,MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATIONACCEPTEDBY v• DATE,IISSUED 4-/S /O AREA: 1 sg <br /> GROUT INSPECTION BY \h v!A d 2a! G-. ; 1 1NAL INSPECTION BY Y 1`[1�r i c, Y1ZcCiL. �, DA7 E,.q._-?O <br /> DEMUCTION I NSPECTION:BY DATE <br /> COMMENTS/CONDITIO)Vs: m r► S s I <br /> ACCOUNTING ONLY: AID# FAC_* <br /> PECODES FEE INFO AMT REMITTED CHECK# RECVSERVICE RO#'D BY BATE. REQUEST PR# INVOICE <br /> 3505 s122 I 1.2.2. 0b 674-3-77 -0;1 4 SR# UoG/OG6 <br /> 3503 344•o0 3G6. oa RO <br /> 350.1? J�T� <br /> PR#' <br /> ' 290D <br /> C-57 1NC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC_„ <br /> EHD 29-01 07/28110 WELL PERMITAPP <br />