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r <br /> aP4'In• SAN JOAQUIN COUNTY f l [_-., <br /> a' ` s ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone:(209)468-3147 Fax:(209)468-3433 Web:www.siaov.oroleh UNIT IV <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,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location I oA AiA1A5_ fr,ol wci Cross Street City/State Le AI,Ch Zip—LI-S040,­ APN0N9-190-17 <br /> Properly <br /> Owner Ale`i o An Or4,r� Address 0n2 we,Y City/State .Pis 1 `,[k Zip 5,IHU Phone 00f� 367-3 gdj <br /> C•57 Contractor NPIn. �,(�Rer_cl� Address qo J- Ln.PUsr r;cl Wu7y_T City/State _Uc.(,6Eecq Phone <br /> Consultant/Sub Cntr Address City/State Uc Phone <br /> Billable Party,r Ile r> .tnlPLrS�t� Address cW- rrid4.Si-r1Q/ W-14 City/State ll r Zip %5�24� Phone �3os�;h ��3�a•/ <br /> GIS Coordinates:X 37, q04/ Y '/2/ 'TG 32 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA OF BOREHOLE_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> —❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _I]INJECTION rl9 Air eoam s)[I HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Bodng Dia:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS 8r BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:rCHECK ALL THAT APPLY) <br /> _a#OF WELLS)TO BE DESTROYEDOVERBORE DIAMETER OF r _INCHES TO DEPTH OF ss FT <br /> WELL IDS: N PRESSURE GROUT TO DEPTH OF --+0 FT BELOW SURFACE <br /> GROUT SPECIFCATIONS o4CA:Ic (PN t-11ih Tyee ' rr - PLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:—[:]AUGERS ❑HOSE bd PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS WZIK l Il Ylt nr ieA 4r1 �'I S enc au hlur+P1- 'Q.rFI- to 4:,3 <br /> r <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby certify t ve prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, all pl le C dornia laws. <br /> Signed Title/Company �2 N�r� �• �'VO�'�!'°w S 9ll�a <br /> Prim Name ` • Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS *z TJP fy77-r° eZ 06W <br /> WORKPLANDATED Ay1510my M14bi5 M914- ;76 ,;!(i/q <br /> APPLICATION ACCEPTED BY�}dre4C#NG k-llt;410ffkli DATE ISSUED; zi�ZG�/�1 . AREA <br /> GROUT INSPECTION BY V1�ki ►+1aCd r�wa� FINAL INSPECT I NN TBY V%'ek. Me f D -/- / <br /> ATE <br /> DESTRUCTION INSPECTION BY VrPldt ryaelbr'IY7R!-f DATE 4-11 -/ <br /> i <br /> COMMENTSICON DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 7116 Z $125X L ZSD� ? L I /LG/�v SR# 69' 30.7 <br /> - I d a7s 375 39500 <br /> 7 <br /> $4Zy zoo P53 7 3 <br /> C-57 V WC WAVER N G57 LETTER OF AUTHORIZATION TO SIGN PERMIT NA' ENCROACHMENT DOC <br /> EHO 29-01 5/09/12 WELL PERMIT APP <br />