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4r}. I.-w..--.,ri'•"retiaawn.r..yup.-rr..��u.v.rr..y..'r.a.w++...nMY�wr...nt Vl.i-•'•'•Y•�-`.t...r..,••�,.nv.iww�n•Mv.-r...r+w.rr./•..yWr✓r-..-.+..r.n..rnwv�.r-•rw'rmv.. - I <br /> .. a:'1r.+:...:T:.+Si.vo-:.e.:�..A'rw.r.[a.w.:Gq.rseti:Y4Y:�:r.sw.w.�sw;..-,�a�rtar.��_tii.ti.,L.ia'ire,:L�-:.a_a:+►V.-.JG:r;x;..H:v'au'a:��x?tnr:� <br /> :. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT. <br /> d r M1: LOP <br /> w. <br /> r SITE MITIGATION <br /> • 600 East Main Street,Stockton,CA 95202-3029 UNIT IV <br /> I Telephone:(209) 468-3454 Fax:(209)468-3433 Web:Mn"jgov.9rgfehd <br /> WELL& BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE ER ES 1 YEAR FROM DATE I D <br /> -Application Is hereby made to San JaaqulA County for a permit to construct andlor Install the work described:This application Is made In odmpliance with San <br /> Joaquin County Development Title,Chapter 9-1115,3,and the Standards of the San Joaquin County Environmental Health Department <br /> site <br /> Location 2�:~,-W• I ikCmssStreet,�ft rAbo X04 CityTrA A zip-952-N-4l� APN��402.21 ? <br /> erty <br /> owner W11 alFrtdu&5 US Address Pb AnK 2 Cltyy.AWnK {Zso Zip,!36�j!g_Phone-2?•ZirZa401 <br /> C-57 contractor CRMW DijiliAlZ Address ft&Wr Rtaa CItyMa_YjjDfM uc.�MjtP 0 Phone gzCh.3t3�b�st�o <br /> ConsultantlSubCntr, Addressri City p OL Lic . PhDne 20 -9U-23:77 i <br /> Billable Partly Address City. Zip Phone <br /> GI.S Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> Q NEW WELLMORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDa <br /> ❑WELL IQ's 1 <br /> CIOTHER IDs.. <br /> TYPE B#OF WELLfBORING INSTALLATION TYPt4 CCQST ORON SPECIFICATIONS <br /> MONITORING [3 HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS 1.3 MUL71-LEVEL WELL CASING DIN <br /> —Cl EXTRACTION:Vapor!Water 0 HAMMERlDRNEN CASING T}IICKNE33 TYPE OF CASING: ❑STEEL ❑PVC E3 OTHER <br /> _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF.GROUT SEAL ' TREMIE TYPE TO BE USED: ❑AUGERS Cl HOSE [3 PIPE I <br /> _❑SOIL BORING E3 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:(3 Yes ❑No(MAXIMUM FREE FALL DEPTH 19'30 FT)' fill <br /> _0 INJECTION UALUI&ILower❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER:' ❑OTHER: APPROXr BORING DEPTH la BOLTED TRAFFIC 90X OR ❑STOVE PIPE <br /> CONDUCTOR <br /> 13 No E3Yes:,Casing Dix Casing Depdr. Borfng Dia <br /> COMMENTS: ; <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT-PERMITS - { <br /> DESTRUCTiON WORKO BEP F RME : CTI L <br /> #OF WELLS)TO BE DESTROYED 151OVER-BORE DIAMETER OF - INCHES TO DEPTH OF 2.G Fr <br /> WELL lDs:_�? 0 t — W1 _ ,,,, _ ®®PRESSURE GROUT TO DEPTH OF ZS Fr BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FRom To FrBeLowsuRFAOE <br /> TREMIE TYP TOB US D; AUG R5 HOSE J fE 0 MUSH O M CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS.NOT.tCE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I Hereby certI that t have prepared this application and that the work will be done In accordance wlth San Joaquin County Ordinances,Rules and <br /> Regular[= no ppN ble California laws. <br /> Signa . a pu TltialCompany f`25 44' �5 rIf S$d <br /> Print Name Data 11410//0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP.IN UNIT tV:FILE-SITE ADDRESS 'r„ a r..e-t� <br /> WORK PLAN DATED Ib 2 t t U' T .. <br /> APPLICATIONACCEPTED BY � t a.�__ DATE ISSUF�S �I IZ �v AREA <br /> GROUT INSPECTION BY _ �r[I+nI�[Gi►-R FINAL INSPECTION BY DATE d <br /> DESTRUCTION INSPECTION BY_. DATE <br /> COMMENTWCONDITIONSWW W' OVIM 0121• 3 b-t <br /> ACCOUNTING ONLY: AID# .FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK N RECY'D BY DATE ' SERVICE RO# INVOICE <br /> REQUEST PRI'! <br /> 3-"-o $122" �- .�s5 . — zn�$K I rz �a SR# <br /> (3o0 <br /> 3503 366 — Z�3fs5 II 13 fU . PRO <br /> z9aD <br /> C-57 jWC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC <br /> EHD29.01 07128I70 - WELL.PERMIT APP <br /> FILE COPY <br />