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ORIGINAL <br /> o"``''iM• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 4: SITE MITIGATION <br /> ••`�" 600 East Main Street, Stockton, CA 96202-3029 UNIT IV <br /> k •: <br /> Telephone: (209) 468-3454 Fax:(209) 468-3433 Web: www.siciov.or_g/ehd, <br /> WELL & BORING PERMIT APPLICATION t}�a� <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVF_STIGAI IONS AND REMEDIAf104 8 "Wen <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 appliea(ion is made in ca�pliance 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 76 V 7 eA6tr16 Al Cross Street R 1 V4 A R V C' 5 t'o TbA' z Za 7 LIr' rr_I N� <br /> tr.00wne ety—OV060�NisuPJ _ ._ Address 16 99DJP WA?' City zip `�S I�! Phone S 8'- <br /> C-57 Contractor --rE 6 Address 11350',"PIVIeC Fmr%Lt.. CRY _Lic 704 Phone(4tiJ kw-82/0 <br /> ConsultanUSub Cntr �4?G _ Address J_S CV PA411 A �t 1?k Cily r Lie. _Phone <br /> Filllahle Party©TG FOR �O f Address Z5 60ftVlQ CIR&LC City'T0�T_zips/7S.S Phom6iO )19h-/tr7 <br /> GIS Coordinates:X 3`y.U 1 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs _ <br /> ❑WELL IDs_._ - -- _ — <br /> I�OTIiER IDs > - S -S "r ntL- V. R <br /> TYPE 8.aY OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _t]MONITORING LI HOLLOW STEM DIA.OF BOREHOLE __ 0 MULTIPLE CASINGS t3 MULTI-LEVEL WELL CASING DIA <br /> _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS _ TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> �®SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIF TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE <br /> ^n SOIL BORING 0 PUSH POINT(GP!CPT) GROUT SEAL PUMPED:❑Yes ES No(MAXIMUM FREE FALL DEPTH IS 30 FT) �t r <br /> _❑INJECTION(.a Ar Saarao Ozon, ❑HAND AUGER_ GROUT SPECIFICATIONS <br /> _❑OTHER ❑OTHER: APPROX BORING DEPTH $ _ ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE <br /> C TOR CAS NG OIN2 Q Yes:Casing Dia: Casing Depth Boring Dia <br /> COMMENTS: 1E"POK�p�Y 5-nt 04P&R P9069=5 <br /> �r <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 DFSTROYED ❑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 he done in accordance with San Joaquin County Ordinances,Rules and <br /> Rogutations,and!!Lapplicable plicable California laws. <br /> Signed _ _ Title/Company <br /> Print Name 13FAI _ - Date.__ L /!Z/�'L <br /> DEPARTMENT USE ONLYZ�oli�,r <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS _ -. <br /> WORK PIAN DATED <br /> APPLICATION ACCEPTED BY -_ __ DAI"E _6 <br /> GROUT INSPECTION BY _ __ FINAL INSPECTION _ <br /> DESTRUCTION INSPECTION BY DATE_ <br /> COMMENI SICONUI I IONS: <br /> ACCOUNTING ONLY: AID# _ FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE O# INVOICE <br /> REQUEST <br /> 350 5 $fix I_ I25.� /J I 1-10-i2-- <br /> 3s° 55 - - <br /> C 57 WC �OOF_ WAIVER r 57 LETTER OF AUTHORWATION TO�SIGNPII _.„ENCIZUACHMF=NT LXIC I Air <br /> FHO 29-01 07r28H0 / �A1FI.1.PI'. <br />