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0 <br /> oA4"•In•. SAN JOAQUIN COUNTY FILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> 1 UNIT IV I <br /> Telephone:(209) 468-3147 Fax:(209)468-3433 Web:www.$)flov.orp/ehd <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 peril 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 3(.q INI"D(JAcross Street rPCEIL Awu6 r City/Stale Sl t6,, Zip 'I5 Z, 7 APN M.,7/y l 0'13 <br /> PropertYLnc.:(r I, reHiro LTD e/c <br /> Owner spm,; Grc,y.u9w,a�rn.n,t C-.a Address 37LI Orrir z Clly/Sta1e5Iw M,,. 7n °7 <br /> ..a Zip'7.5 '7 Phone 2 -`/7,5.9247 <br /> C-57 Contractor Cv.10 n,ne_ cwozno, 4 `ddl Fess 3n. Clly/State�--+-f* LIc 913194 Phone 91b 94.o. 7(41 <br /> Consultant/Sub Cntr EkI"t-WLsi-,Io,. Address 25ZY <Jn-{,,,.,LPhdlb.-F23:� Cily/5latet"­c' Lic Nh Phone 71(,•91(".4376 <br /> Billable Party Address City/State ZIP Phone " <br /> GIS Coordinates:X 38.6I (,ti4 Y IZI'3zI'5Sr] <br /> UO -727. 'z <br /> CONSTRUCTION WORK TO BE PERFORMED:i (.El( &,r` 'C'c-pa;2s Aa2 EXiS{,7�5 (YGYIi Itn llw LJ2115.N� ;7.eti� wzC+(s (v be <br /> El NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ois+,((d- <br /> ❑SOIL BORING IDs <br /> ©WELLIDs 171( 3- oto mul-16-4 c-a Tu - L19 n 1✓-nla "u/-Z -S rrru)'2c47i <br /> ❑OTHER IDS <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> GQ 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(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION a•nrSoame.ownel❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: APPROX BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑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 APPLYI <br /> #OF WELL(S)TO BE DESTROYED [I OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDS: ❑PRESSURE GROUT TO DEPTH OF FTBELOWSURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS <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 /> Regulatlo s,-and all applicable California laws. <br /> ,Signed L- /a^"h— �n�nsr Title/Company eP'g1-PKSb7[CT SCrC�'Irisr <br /> Print Name Date 7 JAa 2-094 <br /> DE ARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS P �Y r " �'V I�O(--r <br /> WORK PLAN DATED pf-de- 9 F(' 32 O f 3 <br /> APPLICATION ACCEPTED BY J-J' O el<u rh DATE IS <br /> GROUT INSPECTION BY FINAL INSPECTION BY nnrF - -� <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PRO INVOICE i <br /> 914"3 $125X ��o ��� `oG U7�r i-�-ly SR# �88zr <br /> RO# <br /> 3500 <br /> PR# <br /> (2900) <br /> I - <br /> C-57 " WC _�—WAIVER/[ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC &LI <br /> EHD 2961 5/09/12 WELL PERMIT AP <br />