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<br /> SAN JOAQUIN COUNTY "*,Rk
<br /> �`n ENVIRONMENTAL HEALTH DEPARTMENT OCT rrwWp— —
<br /> ' � +' 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATIi)N
<br /> \ !' I i lephone:(209) 468-3147 Fax:(209)468-3433 Web:www. C,r %TAI OfffYa
<br /> WELL & BORING PERMIT APPLICATIO—$ r/serawCEs — —
<br /> tNL:LLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION
<br /> NON-REFUNDABLE PERMIT EXPIRE 1 YEAR FROM DATE ISSUED
<br /> Application,i 1 ,.,;,In San Joaquin County fora Permit to construct and/or install the Work described. This application is made In compliance with San
<br /> Joaquin Go a l% . 1 annl Tittle,Chapter 9-1115.3,and the Standards of the San Joaquin County Elnvironfinental Health `/ nt.
<br /> 51ta I_ocatio. I�<<Dyl ( rJL Cross Street V r'n e Cit /State L.D 9 r 7J
<br /> Property y P APN Oil-�U-
<br /> owner 5,_ii (A)� f-/ Address P.o.6 p, 2-49 Clty/State�'�ZiP YS 7/ Phone
<br /> --)— �_ q63 3/c f
<br /> C-5/Cont rca. -{ wro r d. Address S50 IQ.Ver �'a Clty/State Llc 0 Phone Y0Z-3�Y �'fj 00
<br /> Consultanr73,+: n,r{ Ja., Address 303 'L-5'G SIC 500 CRY/State 52rt PrgA LIc K 4 Phone °llS-ZY3.2/s0'
<br /> Billable Party ,yl�y_ ,)¢,,, Address ,90./+-.a_ 4
<br /> -nJ City/State 3a me Zip `(lO Phone .54 M e-
<br /> GIS Coot dina'v.: —
<br /> CONSTRUC'I_Iu)- w tjf K TO BE PERFORMED, —
<br /> L.NEWWELL11i"Idf;(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER)
<br /> �f SOIt ..I;-:IDS_bGJ-Z - .—
<br /> ❑WEI f..�- 19 GW M CW Ili (IL) 72
<br /> TYPE&#OF WI i )RING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS
<br /> Liz MONITOR=" R HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:
<br /> _0 EXT=o?[:t L •Water ❑HAMMER/DRIVEN CASING THICKNESS 'fO TYPE OF CASING: 0 STEEL NJ PVC 0 OTHER
<br /> _0 SOIL VAP( . ❑MUD ROTARY DEPTH OF GROUT SEAL_ 7REMIE TYPE TO BE USED: RAUGERB 0 HOSE 0 PIPE
<br /> i 0 SDu Ftol-:I,- 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yee 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT)
<br /> _DINJECTIU!•. y• (y, EI HAND AUGER GROUTSPECIFICATIONSN&&L CP IMg/)f
<br /> _0 OT HER r_ .,_,.,-, 0 OTHER: APPROX.BORING DEPTH 20 0 BOLTED TRAFFIC BOX OR QI STOVE PIPE
<br /> L'DMMENTCs:
<br /> CONDUCTOR CASING R No 0 Yes:Casing Dia: Casing Depth: Boring Dia:__
<br /> NOTE:: SITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS
<br /> DESTRUCTIOid tri+t.`1:1{TO BE PERFORMED; DESTRUCTION METHOD:! H K ALL THAT AppLyj
<br /> #OFWELI,'.! �I DESTROYED DOVER-BORE DIAMETER OF INCHES TO DEPTH OF FT
<br /> WELL IDs' ❑PRESSURE GROUT To DEPTH of
<br /> GROUT SPECIFG:A I'�I�;,¢ ET BELOW SURFACE
<br /> TREMIE TYPE T:L p:.= C-,F-D:[]AUGERS HOSE PIPE EXPLOSIVES FROM TG FT BELOW SURFACE
<br /> COMMENTS 0 MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE
<br /> 5 W/ i'i DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS
<br /> I hereby certify J -,-ve prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and
<br /> Regulations,pp,i-:r: r,;ilcable Callforrn/iy la
<br /> Signed .-`2 _/` '7e Title/Company G7 e°�/ rt5 LL
<br /> Print,Name I_' _ _�.� G`)'J ez-eaw Date /O h
<br /> DEPARTMENT USE oONLY
<br /> SITE MAP IN UN,I .SITE ADDRESS IAi/l 7 J B ARALY,C
<br /> WORK PLAN DA m Q /91 2 3
<br /> APPLICATION A, i HY -,/. Yo kqKuw DATE ISSUED—/Q-2e-/ t AREA //,Cjc�it
<br /> GROU 1 INSPEC ..___ FINAL INSPECTION BY DATE
<br /> DESTRUC I()N 1 Ir IN By ._ DATE
<br /> COMMENT!;/(:(I -- --
<br /> ACCOUNTING AID# FAC# `
<br /> PE CODF.1; i,AMTREMITTED CHECK III Ili BY DATE SERVICE RO#
<br /> - -QUESTINVOICR
<br /> REPR#
<br /> )-') Scan 13 t<a /v-)l l3 SR# (i835T�
<br /> 3 75 /ux� l
<br /> 37 3 RPRle
<br /> O#
<br /> 3500
<br /> 2800
<br /> C-S5:Hn (` WAIVER—��. C-57 LETTER OF AU THORIZATIQNTO.SIGN-PERMIT r! - ENCROACHMENT-DOC'i __ -
<br /> EH079 ! ,ln'.Y i..
<br /> WELL PERMIT API
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