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SAN JOAQUIN COUNTY li-W <br /> FILE Copy <br /> �0 11 Z03 ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> � < <br /> �y�Z,l�9f T`{1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> •y " .P O=y� f+� C 09) 468-3454 Fax: (209) 468-3433 Web:www.siaov.ora/ehd UNIT IV <br /> F <br /> 4i, �tyVs T SERV <br /> PERMS I 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,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. O i(- C <br /> Site Location Q�OO woe ly,:�./ Qd Cross Street 1G Ci 0 a ��' y <br /> )< _ city Zip 'tS� APN DII -p9D-OS <br /> Proper? l f nl / <br /> Owner/} /l Wt& q-�(rvl Address ?-'12)6 On woo ncd '� City. LOa(,' <br /> Zip? L; r1 Phone At <br /> C-57 Contractor W o o dwcu.rk- Address 550 Ci a <br /> City 0 0}q Phone7o-4-i7�{-r/30'V <br /> Consultant/Sub-CAW Vs,.,.44/J 4-V4 Address 3032=5�- Sie 30v$o.ct,c; Phoney/r-243-2r Ya <br /> 1Y 54 H FTcy Dc n w <br /> Billable Party I(e11nL6y/�a,.k-0 Address 56t H-e City ZJp 9 -/19 F Phone Sa+•--/c <br /> GIs Coordinates:X 62°( 69576 Y Z/ 7 qN, "1"17- <br /> CONSTRUCTION <br /> "i7- <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEWpWIELL/BORING(CPT, EOPROBF� HYDROPU�ICH,HAND-AUGER OTHE[I) CC <br /> 9 SOIL BORING IDS ILLI �f 13-2 -Y!~(� L#I°I-I ic...,8 �(r{-Z.� •� <br /> ❑WELL IDs 8 <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS QE <br /> _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2" <br /> 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: S <br /> _O EXTRACTION:Vapor/Water 0 HAMMERORNEN CASING THICKN SS A h TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER tl� <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH O GhF(' T SEAL_ y_TREMIE TYPE TO BE USED: 0 AUGERS O HOSE PIPE rj <br /> __W SOIL BORING tnl PUSH POINT(GP/CPT) GROUT SEAL PUMPED:[]yes P No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION( ar ,arae o an 11.E HAND AUGER GROUT SPECIFICATIONS JV ea-L G ✓na� <br /> _O OTHER: O OTHER: APPROX.BORING DEPTH_7 0 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING%No 0 Yes:Casing Dia: Casing Depth: Boring Da: 7( <br /> COMMENTS: C <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> —#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF F7 <br /> WELL IDs: ❑ PRESSURE GROUT To DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> COMMENTS M TYPE TO BE USED:El AUGERS El HOSE ❑ PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> CO <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I 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,anQIIappUcabI Calif, is L. -� '// / <br /> Signed LcFC,if � � lz"- � Title/Company C' O •r L- -.oit� }G <br /> Print Name' /ZI :CL.o..P C4eDate I p <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS bG 7 U JneoR <br /> WORK PLAN DATED DE&—1.1,5 F2 (7, 20/Z - <br /> APPLICATIONACCEPTEDBY DATE ISSUED AREA //.4G <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST I PR# <br /> e1 O $125X i 2 o t co R- 1 It 13 sR# 494 383 <br /> 24o 3 376 3)S RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 1z WC ✓ WAIVER—y A- C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC .V n <br />