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401" • SAN JOAQUIN COUNTY <br /> a 5 1'�'J ENVIRONMENTAL HEALTH DEPARTMENT <br /> .K <br /> 010 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> .- ,.r T phone: (209) 468-3454 Fax: (209) 468-3433 Web: www.siaov.ora/ehd I yl(D �� <br /> ENV ....... ly I HEAW /65 <br /> FER(I�IT;�r ,IirE� WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION 165� f/� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title, hapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. /��� 6/v <br /> �/1 ��-1 �r STUc� Z; �3 APN <br /> Site Location u! ��t reef �_- � City, I-Dt3 p 95 <br /> Property <br /> (,�.//r �t�//}EcQ�Q `5l City r51D�ro� Zip 95zz 1 Phone7p`f -9Y1. -oZY( <br /> Owner Address <br /> c-57Contractor ((�'f.I'S1plU S4M1U'�bdress 73La$ I(sw M O2 City STOGtLTvey Lic6c�✓'1o38j' Phone 2o`Y —N(vS 12- <br /> COnsultantlSubCntrC.H'ZM tJ11LL- Address 1$25 AI(L?KU4. city (ZV-00 IQCP Lic Phone 53O-- 227 -3392 <br /> Billable Party C-Y''•2-n LAtw Address 2-52-5 AfKQA2.LL pe_ City - Ir"L Zip I(rv00 1 Phone .�i�0 �7 •^-i - <br /> GISCoordinates:XtJ ��'.�I°I'J IO� Y VJ 121. 315I` (w(I� $-19! DF THIS L►cACN-Laa) <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> , NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs ` <br /> ,WELL IDs <br /> ❑OTHER IDs t <br /> TYPE&#OF WELLIBORING INSTALL TION TYPE CONSTRUCTION SPECIFICATIONS <br /> �r' u <br /> Y_9MONITORING HOLLOW STEM DIA.OF BOREHOLE �D_0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> —❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS��PE OF CASING: ❑STEEL XPVC ❑ OTHER N <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL d- ' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE \`n <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:aYes No(MAXIMUM FREE FALL DEPTH IS 30 FT) v, <br /> —❑INJECTION(e Ar S"rae ❑0z..el HAND AUGER GROUT SPECIFICATIONS CLMbr✓f a�V� <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH, 2- Fr 131eS ❑BOLTED TRAFFIC BOX OR KSTOVE PIPS <br /> CONDUCTOR CASING 113110 Yes:Casing Dia: 410 Casing Depth: Z2- Boring Dia: /0 <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: D TRUCTION METHOD: CHECK ALL THATAPPL ^j <br /> OF WELL TO F�ESTROYED VER-BORE DIAMETER OF INCHES TO DEPTH OF �J FT <br /> WELL IDs: V "9`QJZESSURE GROUT TO DEPTH OF_ _FT BELOW SURFACE <br /> GROUT SPECIFICATIONS w G � EXPLOS IVES FROM TOFT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: ]AUGERS ❑ ROSE ❑ PIS ❑ MUSHROOM CAP AT(>3 FT) _ yFT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby ertify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulati u I licable California laws. <br /> Signed ;2 ��11 Title/Company �ZM NIL-t_ p/tb <br /> Print�e M C- � 3U CA PC K Date �!2 t� <br /> DEPARTME T US PNLYj (1� <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS it'J7/S 1 �lt� <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY T^ISMS ED AREA <br /> GROUT INSPECTION BY - 0 FINAL INSPECTI_ BY r'.a .m DATE <br /> DESTRUCTION INSPECTION BY 05 - 10 DATE <br /> COMM ENTSICON DITION S: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# <br /> O $122x .t0� E to RO# <br /> 210 W I W 3 6 3500 <br /> PR# p7 <br /> 13L DD <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENGRt3!{L/ H E DO PFRMITAPP <br />