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I <br /> ,q. �. SAN JOAQUIN COUNTY <br /> LO <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION <br /> 600 East Main Street,Sto*ton,CA 85202-3029 UNIT IV <br /> Telephone:(209)468-3454 Fax.(209)468.3433 Web:WWW.sigov.orn/ehd <br /> YJi=d14 <br /> WELL & BORING: PERMIT APPLICATION <br /> ' FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <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,Chaplleer 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location '1�00 KOGCr1rL YO cross Street �QC7L.t7?px� City IYp CL,4 Zip APNPro <br /> i ' Ownar 17G�l�P.Syd( h,' �.arr,.,�,t ~' d�d e'ss 3500 t�. city Tfp. A y Zip 'Z0 Phone aCJrT-�3d-393 <br /> C-e7 Contractor I •.• •••u (�XL11 dd cess `JciO 1�iV2/1 �. City i,10,VIS u. Lic-+100'44 PhonejQa--�r(-C�� <br /> i , COnsuIbmI1SubCntr t3Y2S LtrfClY7xl saddmss a A6 rAk OXV4I% SOC(Nyy-n Llc phone91ta "atY>U <br /> ' Billable Party�� Addressa 0 Icy ISQ,fly 511 zipRS833 Phone & (n'49,no <br /> I GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ' ®NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> 1 ❑SOIL BORING IDs <br /> ❑WELL IDs_ TYlw-a3t2 <br /> ' ❑OTHER IDs <br /> TYPE&#OFWELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> itIAMONITORING NI HOLLOWSTEM DIA.OF BOREHOLE O MULTIPLE CASINGS O MULTI-LEVEL WELL CASING CIA: <br /> _O EXTRACTION:Vapod.Water ❑HAMMERIDRR EN CASING THICKNESS TYPE OF CASING.UJ STEEL S PVC O OTHER <br /> ' _O SOIL VAPOR PROBE O MUD ROTARY DEPTH OF GROUT,SEAL .. .TREMIE TYPE TO BE USED: 13 AUGERS Cl HOSE la PIPE <br /> _Cq SOIL BORING O PUSH POINT(GP/OPT) GROUT SEAL PUMPED:❑Yes Q No(MAXIYUM FREE FALL DEPTH IS 3D.F7) <br /> ..OtNJECTIONIte.Airswme.ozonm❑HANDAUGEFtGROUT SPECIFICATIONS ILl P.:l52A 0A14A0r 77_ <br /> ' _0 OTHER: ❑OTHER: APPROX.BORING DEPTH Q O BOLTED TRAFFIC SOX OR JASTOVEPIpE <br /> COMMENTS: CONDUCTOR CASINO O No 0 Yes:Casing Dia:�Casing Depth:_Boring DW <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PER. <br /> DESTRUCTION WORK TO BE.PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OFWELL S}TO BE DESTROD (OVER-BDREDIAMETER OF_IQ_INCHESTODEPTHOF o'�I F7 <br /> WELLIDs: 'F' ❑PRESSURE GROUT TO DEPTH OF FTBELOWSURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑.MUSHROOM CAP AT t>_3 FT) FT BELOW SURFACE <br /> ' COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 1 hereby certify that I'have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations;anndd all applicable California laws. /� l <br /> Signed _ G— TitiefCompany Q �"�,� �" �^-' �/'tAfz�s <br /> Print Name_\J2 I-e OOL(414, Date SII5FIS91k _ <br /> DEPARTMENT USE O LY <br /> ' SITE MAP IN UNIT IV FILE-SITE ADDRESS a'65'1t Y0 Srp sA /?r,. <br /> woRK PLAN(DATED <br /> APPLICATION ACCEPTED BY_(,tiy!A AeZ4 t_ DATE ISSUED 4 1 IF .AREA. <br /> ' GROUT INSPECTION BY PINAL INSPECTION BY DATE <br /> DESTRUCTION.INSPECTION BY DATE <br /> COMMENTS/CONDITIONSr <br /> ACCOUNTING ONLY: All)If FA" <br /> PE CODES FEE INFO AMT REMITTED CHECK.# REGV'D BY DATE SERVICE PR# INVOICE <br /> RUE <br /> $122x t I I/z2 rs it<Z' N ful it SrYR# 6zy&Z <br /> OC lVG- 1 •. 4 V.A t�' .Od <br /> `i366. 0 0 5�s <br /> EHD WC WAIVER G-87 LETTER OF AI)YHORIZATtON T13 SIGN PERMIT y,✓ENCROACHMENT DOC <br /> EHD0-0 <br /> ' 21 >rn28110 WELL PB2MiT APP <br />