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SAN JOAQUIN COUNTY i V <br /> 4. ENVIRONMENTAL HEALTH DEPARTMENT OCT <br /> ZUt�os — <br /> � aL�6' 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> SITE MITIGAI i rhl <br /> elephone:(209) 488-3147 Fax:(209)468-3433 Web:www.siao r ENTAL { __ <br /> WELL & BORING PERMIT APPLICATION IT/SERVICES <br /> e iULLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM QATE ISSUED <br /> Application Is I, oc 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 I, :n,lent iltle,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health t�nt. <br /> Site Location ;(LLA—Ll U4 Cross Street Ur-ne/ LOd �' `Y <br /> Property, City/State Zip APN e -�()-_�`/ <br /> Owner ):r_i.1 �i CA) I Address <br /> $�5o♦2,Uol+ Q .� cltyisataJzpY '7Phone <br /> C-57 Con' Address 0 Clty/StatetnNlUc 0 Phone�iOI9Z26;7j3y-3'Yj`0f <br /> 0ConsultaflWz Address <br /> City/State 50-, Fr4r Lid 1%9 Phone 4ilS-ZY3-7/S0' <br /> Billable Party-_. . r��„ Jq„ Address Sa ti� City/State n4MCU ZIP 9 Y!O Phone 54 Al C_ <br /> GIS Cooldina,:: . Y ZZLf4O7LI- <br /> CONSTRUC-it:z! nrIJRK 70 BE PERFORMED, <br /> (A NEW WELL./1 fO"Wv(:(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> SOIL Us r>GU-Z? A - <br /> WEI . a � .>_� G W Z-U r Lu I l i C 41 <br /> C0 ', _ _ <br /> TYPE&#O IA,; a THING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I <br /> ALO MONITOR. : l$HOLLOW STEM DIA.OF BOREHOLE 8_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _t7 EXTRACT''. :.. ly.wl 13 HAMMERIDRIVEN CASING THICKNESS SGYo TYPE OF CASING: (]STEEL 0PVC 0 OTHER_ _ <br /> _0 SOIL VAP( 0 MUD ROTARY DEPTH OF GROUT SEAL�TREMIE TYPE TO BE USED: CRAUGERS 0 HOSE 0 PIPE <br /> I IF Son Bnr-:u- 0 PUSH POINT(GP/CPT) GROUT SEAL PUPPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH 15 30 FT) <br /> _D INJECTIC)i (y >x ..,10 HAND AUGER _GROUT SPECIFICATIONS En t <br /> —0 OTHER:_., _. 0 OTHER: APPROX.BORING DEPTH _ 7 (] 138 OLTED TRAFFIC BOX OR IQ STOVE PIPE <br /> COMMENT:i <br /> CONDUCTOR CASING R No 0 Yes:Desire Dia: Casing Depth:_ Boring Dia:__ <br /> NOTL.: -SITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTIOit!Ir Q, R' .r0 BE PERFORMED: <br /> DESTRUCTION METHODR(CHECKINCHES <br /> TOD <br /> #OF WELL.SSI -.r DESTROYED ❑OVER-BORE DUIMETER DF INCHES TC DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT To DEPTH OF <br /> GROUT SPEC.1I,: .F FT BELOW SURFACE <br /> TREMIE TYPE T:iIaEO:[]AUGERS HOSE PIPE El EXPLOSIVES FROM TO FT BELOW SURFACE <br /> COMMENTS--. ❑MUSHROOM CAP AT L>3 FT) FT BELOW SURFACE <br /> 5 1N13'•'.,..�;G DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPEC71ON APPOINTMENTS <br /> I hereby certify ,i,r, '.,ave prepared this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,W!:.I� _111cabie CV1foritin Iayrys" �' /' J <br /> Signed ,��/� : � /!%C F-eMG7 / ` <br /> Title/Company LSO O r S Lr- <br /> Print Name, cData <br /> DEPARTMENT USE pONLY <br /> SITE MAP IN(INF. ! I--SITE ADDRESS /f3 667 /1/ � 8 B RAL��C <br /> WORK PLAIN DA I SG-PTEM REF /9 — <br /> APPLICATION A:'-. joy -.l. TQ ✓dK4rin DATE ISSUED &O-2(f?•/3 AREA <br /> GROU I IN.S-PEi' _ __- FINAL INSPECTION BY DATE_/ _ <br /> DESTRUCT"K)N.� -. u)IdSY, DATE <br /> COMMENTS11:0, <br /> ACCOUNTINis., i" -j� AID FAC# <br /> PE CODE' ! AMT REMITTED CHECK# Ill BY DATE SERVICE RO# <br /> ,I -- -- - --- REQUEST PR# INVOICt <br /> Scz� 37y rea i0-lr , <br /> 3 sR# G83s� <br /> 3 ?5 /tr o 137 <br /> 3 RaSDoo _ <br /> 5, I LT PR# X835/ I <br /> 2900 <br /> C-57 (� WAIVERS C-57 LETTER OF AUTHQR�ATLQN TA_SISx.N.PERMII_-_..x ENCROACHMENT-0OC <br /> EHD 2.1-11 '( WELL PERMIT ', - <br />