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{ � <br /> Aug 06,1308:55a Microsoft • 83T662-8179 i P.1 <br /> I i <br /> s fn SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> '$1p 1868 Hazelton Avenue,Stockton, CA 95205-6232 SITE MITIGATION <br /> UNIT IV <br /> Telephone:(209)468-3947 Fax:(209)468-3433 Wc6:www.sigov.orglehli <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 /> Applical(on is hereby made to San Joaquin Counly for a peunit to Construct and/or Install the vmk described. This applicstlan Is made In compliance Will San <br /> Joaquin County Development Tale.Chap) r 0-1115.3,and the Slandards of the San Joaquin County Environmental Health Department <br /> Sltat.ocatlonM W �a's'c Grossstreet N•T+-"l Wyor Gity/StateT Cln4 Zfp t])_ APN XIA-6�a' a <br /> Property , (aZ.� L-awrertce Dr �'n4oT to `r7 340 i PhSp,40&-J44-?r12-o <br /> Owner I _LL'�-�� Address_ CitY/Staten P <br /> C-57Conlractor C Addimly_ �_ tJ y 1 GiIY�CatP.(•}pl'o C tic 4Swt70 PRone 78 <br /> COnsultantisubCntr Address _ Clty/Stale Uc��,,�--Phone,S"fd-:+N9-fBES"� <br /> Billable Party E12A-5 Address t ,�33 8 Clty/Stale wpr Ip l`te "I Phone S(�d <br /> CIS Coordinates:xYt •.AAI Y1�3�"JS' ,�,�.7'Zq/ <br /> CONS CTION WORK TO BE PERFORMED; <br /> NEW WELUBDRING(OPT.G R BD UPUN'H,JJAND-AUGER.OTHER) <br /> J�/601L BORING IDs :c �S 3 <br /> • ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&AOFWELLISORING INSTALLATION TYPE CONSTRUCIMNSSPECIFICATIONS <br /> _❑MONITORING Q HOLLOW STEM CIA.OF BOREHOLE 4—Ir 0 MULTIPLE CASINGS 0 MULTFLEVEL'NELL CA9NG DIA: <br /> _0 EXTRACTION:Vaporl Watar jVgAMMERIDRIVEN CASINGTHICKNESS _TYPE OF CASING: [I STEEL El PVC ❑ OTHER <br /> _11 SOIL VAPOR PROBE QMUD ROTARY DEPTHOFGROUTSEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPET <br /> '2�SOIL BORING (3 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0Ym O No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION a,ARSwans.camel❑HAND AUGER GROUT SPECIFICATIONS <br /> _OOTHER: [I OTHER: APPROX BORING DEPTH Q BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No D Yes Casing Ole:_Castro Depen_aonng Dia:_ <br /> COMMENTS---_-..— <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD-rGHEOKALL THATAPPLY) <br /> /FOFWELL(S)TOSE DESTROYED ❑OVER-BORE DIAMETER Of a1CHESTO DEPTH OF T_ <br /> WELL We ❑PRESSURE GROUT TO DEPTNOF FTBELOWSURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM iO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE 3KPIPE ❑MUSHROOM CAP AT L3 FT) IR eELow SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> TS <br /> hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin County 0ldlnances,Rules set <br /> Rogolationa and allppl- pts California laws. fYQ i - a <br /> Signed TillelCampeny- <br /> Print IN te <br /> a J DEPARTMENT USE ONLY <br /> SI IF MAP IN UNIT af FILE-SITEADDRES//S� 3� 46RO21Y Rd-41) R L <br /> VVORK PLAN DATED J�L-r/�•5T T1�r 3 <br /> APPLICATION ACCEPTED BY_ /. `I OtAJJCYfe"� DATE ISSUED i3-y r/-/3 AREA, / <br /> _ GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY, DATE <br /> COMMENTSMONOITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK R RECV•D BY DATE SERVICE ROA INVOICE <br /> REQUEST PR# <br /> yvS s,zSX I _ S 2» �kwT g-7-i3 sRn 67776 <br /> X90 3T5 RO# <br /> 3600 <br /> PR# <br /> (2900 <br /> C-57 WCWAWER JI/6 C-5T LETTSR OFAUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC�/>� <br /> 011)29-01 v1091t2 WELLPERMITAPP <br />