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ip <br /> SAN JOAQUIN COUNTYENVIRONMENTAL HEALTH DEPARTMENT_ " LO SITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> Telephone:(209)468-3147 Fax:(209)468-3433 Web:www.siclov.oroleh <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 andlor 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 `f0a ToAUS� Cross Street City/Stale I—Deli/(r} Zip `ISONO APN <br /> Property <br /> Owner /hell n. PriyA0rSor) Address gs2 :r,2a stnaI Wc9 City/State )L�, I,ck Zip `I5„210 Phone 061) 3151-3 e1 <br /> T <br /> C-57 Contractor Address qO JL SnAUst ricl 1N4CitylStateI j i r a Uc L(�/�` ``!`! Phone �3 c5')36}-39c1 <br /> Consultant/Sub Cntr Address T City/State Uc Phone <br /> Billable Party,htp-I o. Mv�rrSun Address Tal rrtrlkS+rIG/ L1/0.4 City/State I r Zip y.5.14a Phone 7<3el <br /> GIS Coordinates:X 37, 909/ Y ^)21 .26's <br /> I <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER to <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS ❑HOSE 0 PIPE <br /> _0 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _OINJECTION(Ia Air Soame.OzonelOHAND AUGER GROUT SPECIFICATIONS <br /> _O OTHER: 0 OTHER: APPROX BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth:_ Boring Dia:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:rcHECKALL THAT APPLY? <br /> __a_#OF WELL(S)TO BE DESTROYEDOVER-BORE DIAMETER OF r (LACHES TO DEPTH OF_TUFT <br /> WELL IDs: PRESSURE GROUT TO DEPTH OF + 4o FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Oer`+land (a.WlenY(p <br /> r TP �i_ PLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE hd PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS Wellc L1d11 ITz nr Js <br /> id `�n'f S( �tbunl wn4?f' f.li FS-I »w�� a Ft t�.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 /> RegulationaO al/lp 1pl to C ifornia laws. ,I <br /> Signed '✓ ,l Title/Company l2&f. NEk- <br /> Pdnt Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS f62 �NIXf5r1-°iAtt.. In/A'�/. G/rA/ <br /> WORK PLAN DATED )t8 vi5 i 01 1 S M K 9)�• 26 ZAlq , <br /> APPLICATION ACCEPTED BY,.,4 0edd tVISfj'0f rL DATE ISSUED; AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> I <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# <br /> PE CODES FEEINFO AMT REMITTED CHECK# RECV'D BY DATE INVOICE 'i <br /> +�q /' 7 41 /W'///y SR# 4REQUESTCI qPR# <br /> v/6 Z <br /> $125, L' ,�'Z7r0` 0x JC-0 <br /> RO# <br /> -z 6 7,75 3500 <br /> 4 zoo 053 7 a <br /> C-57 V WC WAIVER 7/V=7-57 LETTER OF AUTHORIZATION TO SIGN PERMIT N&- ENCROACHMENT DOC <br /> EHD29-01 5/09/12 WELL PERMIT APP <br />