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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT OCT rfl ZUuOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGA'1'f:iN <br /> l elephone:(209)468-3147 Fax:(209)468-3433 Web:www.Siao ENTAL {klhT}�t <br /> WELL & BORING PERMIT APPLICATION IT/sElnces <br /> 1 "HELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is I :,ie m San Joaquin County for a permit to construct and/or install the work described. This application is made In Compliance with San <br /> Joaquin t 00111, �.�,neral Title,Chapter 9-1115.3,and the Standards of the San JoagWn County Environmental Health y tteent. <br /> Site Location : t/f dh ( Gl Cross Street l o c n e/- City/State L o 9. , Zip�cAPN Oil-0 0- <br /> Owner <br /> - Q� <br /> Property Q �u �J <br /> Owner 5:_(I. (�J,y�y 1 � Address E 0. 6 Ux 7_y9 Cit /State A Zl YS / phone <br /> ---� y P� `I63 /6Y <br /> 057 Conti :. �, d Address S50 i2 von 12'a city/state Up o Phone 7Y07-37Y -Y3oo <br /> consultaDr? rM V �a„ Address,363 2 55-t SY_r 500 <br /> City/State�.n Fran Uc 11 l- Phone HlS-Zy3 ZC _o' <br /> Billable Pal ty ,/ J.a„ Address S0.w.z City/State 5a -1B zip 4 YlO Phone 54 lw C <br /> GIS COOIdiilaL --fa_1`L_P� _Y 2Z`{KO 7 L <br /> CONSTRUC'(!t:u woRK TO BE PERFORMFD- <br /> [K NEW WELLn u P irf(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> � SOn_.. 11Ds r cI-z2A <br /> WE-I li <br /> of i-i <br /> TYPE&#UI=IAI ,; )RING INSTALLATION TYPE OONSTRUCTION SPECIFICATIONS <br /> -[MONITOR:': ®-HOLLOW STEM DIA.OFBOREHOLE8, O MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: <br /> _LJ EXTRP.':'I I. "Yater 0HAMMERIDRIVEN CASINGTHICKNESS SC_4 40 TYPEOFCASING: OSTEEL Et PVC 0 OTHER <br /> _0 SOIL VAF'( ❑MUD ROTARY DEPTH OF GROUT SEAL <br /> �TREMIE TYPE TO BE USED - <br /> : MAUGERS 0 HOSE 0 PIPE <br /> !. CJ soil !wl—:I� 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yea 0 No(MAXIMUM FREE FALL DEPTH IS 30 Fri <br /> _0 INJEC 1 X01, 0�.'.)❑HAND AUGER GROUT SPECIFICATIONS/�P_t�.-✓; C.P I//'I _n L` <br /> _0 OTHEN._ _. Q OTHER: APPROX.BORING DEPTH Z O ❑BOLTED TRAFFIC BOX OR IQ STOVE RIPE <br /> COMMENTS, <br /> CONDUCTOR CASING R No❑Yea:Casing Die: Casing Depth:_ Boring Dia:__ <br /> NOTI!-:_ SITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION_I,�! BE PERFORMED: DESTRUCTIONMETHOD•ICHECK ALL THAT APP <br /> #OFWELLI'.) DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs:__ __ ❑PRESSURE GROUTTODEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFiI " ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE t:. �:;FD' ❑AUGERS [:]HOSE ❑PIPE ❑MUSHROOM CAP A7(>3 FT) Fr BELOW SURFACE <br /> COMMENTS,.__, <br /> 5 WI DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby certify rre prepared this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulationi ,i icable Calfforgo I <br /> Signed 5 _ Title/Company G7-Ao//i "S iL <br /> Print Name l '- _ _�� y'I'J Cz_eop/ Date /0A <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN LII,II -SITE ADDRESS Al O B 81_?AdK <br /> WORK PLAN DA SC-PTEm REF /91 2e l '3 <br /> APPLICATION A, J7 BY J. To ✓dKtcm DATEISSUED 7f]-Z•/3 AREA 16eYA <br /> GROUTINSPGC„... . _ FINAL INSPECTION BV --r <br /> DATE <br /> OESTRUCTIUM a ON OY_ DATE <br /> COMMENTSA u;.',. —' <br /> rACCOUNTIRK-i ' AIO# FAC#AMTREMITTED CHECK# RECVD BY DATE SERVICE RO#REQUEST PR# INVOICF <br /> 5c� 37y /0-11-1 SRO �c335Z�75 levo /37 3 RO 3500 <br /> 2-T <br /> T . PR2900 <br /> C-Sr VAINER <br /> EFC21 li _ YL ' C-57LETTEROFAU7HORa&TJVNTOSIGNPERMT. vENC <br /> ROGASCH3MSEN <br /> T DOC � <br /> WELLPEERMIT <br /> rU v' <br />