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SAN JOAQUIN COUNTY <br /> —` ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> c. = SITE MITIGATION <br /> 600 East Main Street, Stockton,CA 95202-3028 UNIT IV Telephone.'(208)468.3454 Fax:(209)468-3433 Web:www.siaoy.oratelid ED <br /> WELL & BORING PERMIT APPLICATION ���.+�� y G <br /> ' FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION MAR 17 2011 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to Sen Joaquin County for a permit to construct andlor Install the work described. This application Is RISK S <br /> Joaquin Courcy Development TBIe,Chapter 8-11111.3,end the Standards of the Son Joaquin County Environmental HeaXh Depanmerd APEALTH <br /> 1 - PERMIT/SERVICEES <br /> She Location T*3 6oO 1f:OSsan IM Cross Street )_ 0nze-" CNy�_Lp 95'304 APN 43`I- Ia- f <br /> coir 1Y -\ zrs NO&dmss amp I=h�r 12.6- city$ _ZIp$L24_�LPhone 5�- 34 <br /> C-57Contmctor :JiYhr e—Y�JM_ Address I1a91 Cho"`� city Uo 3.Phone 4`i— 730 <br /> ' COnsultendSUb Cntr Addrem AQI9O ( I1.L'Wr** Z-Pbily-��Lic Phonegllo-&'A-AOhh <br /> BWable Party>J S � or1 Address ��1 C20k&Y1.1}-(ayK Cfty Zip�honc,242 CJL.> <br /> GIS Coordinates:X Y - 1ST <br /> MkXtK TO BE PERFORMED: <br /> Ru (CPT,GEOPROSE,HYDROPUNCH,HANDAUGER,OTHER) <br /> SOIL BORING IDs <br /> 1C3WELL IDs <br /> ElOTHER IDs <br /> TYPE S e OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _Q MONITORING D HOLLOW STEM DIA.OF BOREHOLE _Q MULTIPLE CASINGS Q MULTKEVEL WELL CASING DIA:_ <br /> ' _O EXTRACTION:Vapor/Water Q HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL D PVC D OTHER <br /> _D SOIL VAPOR PROBE Q MUD ROTARY �,1 QEPTH OF GROUT'SEAL TREMIE TYPE TO BE USED: Q AUGERS D HOSE I]PIPE <br /> _D SOIL BORING C9 PUSH POINT(GPI CPi r+.%yt4ROUT SEAL PUMPED:Q Yee D No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> 'WUNNJECTION OA A,Sew.o.i D HAND AUGER GROl7T SPECIFICATIONS <br /> ' _D OTHER: D OTHER: APPROX.BORING DEPTH _ate ❑BOLTED TRAFFIC BOX OR D STOVE PIPE <br /> _ CONDUCTOR�ASING Q No D Yea:Caanp qla: Cpnnp Dept :�Sonrq Dia' Il <br /> -' <br /> COMMENTS h1ur' •1&X1 -1--a(�x.y�allp s cs1' FfS �I'll+lrr'1 Srllu'h m. 101111 OI,T. Sl ✓]��Ile <br /> NOTE: OFFSITE WELLS Il BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> TO W ORMED: DESTRUCTION MMOD•(CHECK ALL THAT AepLY1 <br /> f OF WELL(S)To BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO OEM OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO OEM OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS D EXPLOSIVES FROM TO FT BELOWSURFACE <br /> ' 7REMIE TYPE TOB USE ' AUGERS HOSE PI MUSHROOM CAP AT e3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 6 WCINKIING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I kava prepared this application and that the Work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applisojohoigellformla <br /> Signed `__f Title/Company LASU <br /> Print Name tYlnrt io 'D aAM(IY�C.( Dale 11 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE A RESS I,L�.SOO KG,-Wa + M <br /> WORK PLAN DATED ipally <br /> APPLICATION ACCEPTED BY /��-[rrmCs�i— ___ DATE ISSUED^S / AREA _ <br /> GROUT INSPECTION BY FINAL INSPECTION BY Tom^ DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ECODES <br /> NG ONLY: AID i FAC a <br /> FEE INFO AMT REMITTED CHECK a .f RECV'D BY DATE SERVICE ROA INVOICE <br /> REQUEST PRO <br /> ' S122z �Z2:,�� SRA Z 3 1�' II sem 366•oo z <br /> RN <br /> C57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ___ENCROACHMENT DOC <br /> EHO 2Pe/ 0742811D WELL PERMIT APP <br /> i <br />