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SAN JOAQUIN COUNTYFILF <br /> �. .o <br /> E vVIRONMENTAL HEALTH DEPARTMENT LUF <br /> ` SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> ��....•:�:�;:� Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br /> ��FOR <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 <br /> pof/Ithe San Joaquin County Environmental Health Department. (� <br /> Site Location 76 V 7 'PAGIF/CAYL-Cross Street R ✓ARq Ry• City S'-OGKTO�+/ Zip Jf L°7 APN 7 f <br /> -,r1tjowner 60,14OWF1111"Ps Address7� RVAP ✓w City 5_Ar_'9AA1&M zip-VPhone(*4)SS8-T03 <br /> C-57 Contractor 0%6 T Iur,t G <br /> Address y f0 /I01-IF R9. City/''1 9TL✓Q Lic Phone <br /> Consults Sub Cntr ATI! Address Z5 6YFA-11A 61R. CitY! ,tl Lic Phone 40" Wj -IZ17 <br /> Billable Party 4.1C, FOR GOP Address 25 411PIWI 4 GIR. city1wff Zip _Phone(&S) IuQ6-/Z!7 <br /> GIS Coordinates:X Y -/Z/. 32 `I <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT.GE PROBE,HYDROPUNCH,HAND-AUGER,OT <br /> I- C?SOIL BORING IDs - G <br /> - oLOi✓- TecN► AVHER <br /> 6- ®WELL IDs-AAA-W-17 7' <br /> OTHER IDs - - <br /> TYPE&#OF WELLJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> b�\V <br /> MONITORING ElHOLLOW STEM DIA OF BOREHOLE OG iI ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: M <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS $LA 410 TYPE OF CASING. ❑STEEL jYPVC ❑ OTHER � <br /> _LJ SOIL VAPOR PROBE [3 MUD ROTARY DEPTH OF GROUT SEAL o ' TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE PIPE_(T` <br /> 1�SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:54 Yes ❑ No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.Air Sparge_ozone)❑HAND AUGER GROUT SPECIFICATIONS iCEA1&•_-T 6Rav7 <br /> _❑OTHER ❑OTHER: APPROX.BORING DEPTH _L10 '/6 a ( BOLTED TRAFFIC BOX OR ❑STOVE PIP <br /> CONDUCTOR CASING ❑Yes Casing Dia: Casing Depth: Boring Dia <br /> COMMENTS:ff/�LCow tvELLf 1 <br /> 0 yo,, p¢y WdLt� •Tp 60 <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 ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑ PIPE ❑ MUSHROOM CAP AT(?3 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 /> Regulations,and all ap2licable California laws. <br /> Signed ��1 �s ---- Title/Company /n' /�0✓��/x'1964 -�4T� A55oG>+�T� <br /> Print Name (!�� G��l�-E'y Date /2 .3Z/1 <br /> DEPARTMENT USE ONLY �— <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 76 < 35t(o <br /> WORK PLAN DATED 2 2-- / <br /> APPLICATION ACCEPTED BY DATE ISSUED Z AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> REQUEST PR# <br /> So $ 1212x (p b, / /. SR#�� C <br /> Sad �it� �J�S. /A) �� (/ I✓ 3 00 >� <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO 91ftRMMO 'ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 WFI I PPPKAIT APP <br />