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{ o FILE COPY <br /> SAN JOAQUIN COUNTY <br /> EP 16 2011 LOP <br /> SITE MITIGATION <br /> HEAL 600 <br /> HEALTH DEPARTMENT <br /> ENT BEA <br /> ONM 600 East Main Street,Stockton,CA 95202-3029 <br /> UNIT IV <br /> IMIT/%pe"CE <br /> -3454 Fax:(209)468-3433 Web: jq riv.oo i!d <br /> ........... phone:(209) 468 --_-A ------- <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CON TAMIN.ANT INV- .'-STIGATIONS AND REMEDIATION 'W <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1 ij:.01 <br /> Joaquin Count,,Development Title,Chaplet 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location <br /> .e&Toss Street Mevly7-AlAllwJ� city I-AAC)( __Zip_ APN 201-2-50 - <br /> Property 4112RWAy <br /> Owner 15#,EA Mt2a4LLA4­u-j4",pAddress L�p Sq_ y <br /> C-57 Contractor :rs /-Le-Address ,.-A _,C.e&re&,6A _LjkejtA6Iep Zip*tj Phoni§ q2_CZ�q6'0 <br /> —V City--4&-,T <br /> Ilif?- ,eFZOLic qZ6,OA�- Phone <br /> Consultant/Sub Cntr.___C R A Address7;147/t/ 44 Lic Phone -zc,- <br /> _qq 'el4ecAj—weity <br /> Billable Party Address <br /> '&e City Zip Phone 707 <br /> GIs Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> n NEW WELL/BORING fCPT.GEOPROBE,HYDROPUNCI 1.HAND-AUGUR.OTHER) <br /> El SOIL BORING IDs <br /> El WELL IDs <br /> F1 OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPE <br /> I-,IC JL CASING!]!A:A: <br /> )NITOIRING 0 HOLLOW STEM DIA.OF BOREHOLE [I MULTIPLE CASINGS 0 MULTI-LEVEL WELT_ <br /> _Fl EXTRACTION:Vapor/Water [I HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL [-]PVC C] OTI IER <br /> E]SO11 I/Af1CR,PROBE ❑','!j[)rC.TAR.',' U!-; -;HOF GROUT CEA_ t fl'L m,IF-I C]'!'I <br /> 0 SOIL BORING ❑PUSH POINT(GPI CP f') GROUT SEAL PUMPED.El Yes El No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —E]INJECTION r1e Air Sparca.Onne)[I HAND AUGER ____GROUT SPECIFICATIONS <br /> —0 OTHER: 0 OTHER, APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR [I 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:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED El OVER-BORE DIAMETER OF INCHES TO DEPTH OF 3 FT <br /> WELL IDs: M 04- 5 klP- I El PRESSURE GROUT TO DEPTH OFA d4-'d FT BELOW SURFACE <br /> GROUT SPECIFICATIONS E]EXPLOSIVES FROM TO FT BELOW SQRFA(-,F <br /> TREMIE TYPE TO BE USED:0 AUGERS []HOSE [X PIPE ❑MUSHROOM CAP AT(?3 FT)_ -T—rT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFT I ER 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,and rnia laws. <br /> Signed - —Title/Company 9'AS504A-r-- <br /> F645-Ir-1 C., Date <br /> Print Name !!j ZI'C IZ-d <br /> DEPARTMENT USE ONLY-�� A <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE ISSUED ARF <br /> -�Tl- <br /> GROUT INSPECTION BY FINAL INSPECTION BY )I,jPqg4!Kj —DATE 10-I(W <br /> DESTRUCTION INSPECTION BY.- 0*X"'vI DATE CO2MVE!"M <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO 9 AMT REMITTED CHECK# RECV'D BY DATE SERV # INVOICE <br /> REQUEST PR# <br /> 2-902— SR# 010 <br /> 719 9 5 kAp5-U-� <br /> R# <br /> WC, WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERK. Doc <br /> Ei-ID29-01 07J26110 )`F-LL PERMIT APP <br /> t/ <br />