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SAN JOAQUIN COUNTY • FILE COPY <br /> r. Z ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> 1868 East Hazelton Avenue,Stockton,CA 95205-6232 SITE MITIGATION <br /> 1 p Telephone:(209)468-3454 Fax:(209)468-3433 Web:WWW.sigoV.Orglehd 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�61�H Re..jww,n Hc++Tx. Cross Street �nG�ti�A City Sl Ac N ZiprL52O-7 APN 0`(7 "110 7 3 <br /> Property L-"dc1�YrCD`Pe-r E5 Lrp/cti . <br /> Owner SIMS F- frAr.l- Ccs' Address Ll.e.cln Cz.� ! City�gcv�� ZIp25207 PhoneZOc <br /> C-57 Contractor�Sl,ScaALDrxx LV :L2 Address C0o DL�1 tx�i.,�f1- City`MG GL .`ne, Ucq-,�jjlo Phone`jll(`( a <br /> Consultant/Sub Cntr FILM T— Address _Ztiili N)k •r,r V rLDr. Ori Ib S _ :3k-ll� <br /> r <br /> ccsc,unir Lic Phone Jlb-yZ4-Y37$ <br /> Billable Party 02-M Address (Sae o.Loc.,c1 City _ZiP -45833 Phone 5�,- c.loov <br /> GIS Coordinates:X39.0165LI Y -L2L3Zlfr59 <br /> CONSTRUCTION WORK TO BE PERFORMED. �-o,ti(C <br /> IANEW WELUBORING(CPT-,EOPROBE,HYDROPUNCH,HAND-AUGER, <br /> ❑SOIL BORING IDs <br /> 19WELLIDs_ !-W-IAU/3:W-IALi 'SW-2 AU�SH/ z.Al-. n1t.� loc? -Al.� rt� -qL L,,:IRO -,4L M � 1"31 4ln llti\I <br /> [:I OTHER IDs I/ , <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Z MONITORING M.,,r,.,r„IMW;,-Aid HALLOW STEM DIA.OF BOREHOLE tZ' ❑MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA:�_ <br /> _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS Zn Stl` YPE OF CASING:A STEEL APVC 0 OTHER <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL Z I TREMIE TYPE TO BE USED: AUGERS 0 HOSE PIPE <br /> LW-L1MLI 0 <br /> _❑SOIL BORING 1GW-TA <br /> =W- nW_lAV p PUSH POINT(GP!CPT) GROUT SEAL PUMPED:JR Yes El No(MAXIMUM FREE FALL DEPTH IS 30 FT)2=-14 <br /> INJECTION(Le.t_Boame.Ozmell❑HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: 0 OTHER: APPROX BORING DEPTH '_ (' 19 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING%No 0 Yes:Casing Dia; 7� Casing Depth: Boring Dia:_ <br /> COMMENTS:munilvri,.44x.i1� S �K ke}yr� 0 2° YH 40 j�!q �f {tom 115 neeio w 11 L 2 <rh8 PJe. / Z' Ski <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS F" ^ <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD• HECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> GROUT SPECIFICATIONS <br /> WELL IDs: ❑PRESSURE GROUT To DEPTH DF FT BELOW SURFACE <br /> ❑EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE <br /> COMMENTS ❑MUSHROOM CAP AT L3 Fn FT BELOW SURFACE <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 /> Regulation?,and all applicable Cali o�rnia^Laws. <br /> Signed pjM I� Title/Company �2YYl <br /> Print Name; L;csiks4y MfL(Sk Date <br /> (� DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS I f3Cf!j/C t REN NOL.T <br /> WORK PLAN DATED I <br /> APPLICATION ACCEPTED BY -(- DATE I ��ti' 'A /(� <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE 9-/2•l3 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING qFEEINFO <br /> AID# FAC# <br /> PE CODES AMT REMITTED CHECK# RECV'D BY DATE SERVICE RD# INVOICE <br /> QREQUEST PR#Yy�O cid 8-f5 .1 SR# 8 '3 <br /> 4o3 RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 A, WC_�LWAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />