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SAN JOAQUIN COUNTY <br /> ��• --�--, :� LOP --- <br /> .� ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION <br /> • 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> '4*x9ii <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sigov.orglehd <br /> WELL & BORING PERMIT APPLICATION D <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND RE DIAT <br /> -)y <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 pof the San Joaquin County Environmental Health Department. (l <br /> Site Location& 7 7 1PA61 t'lCA -Cross Street cityiTOGKT4� � �Zip � APN 7 <br /> .'Z o ;er Address7( Bt-1,QOADI./4)' City RAS Zip Mlff Phone&6)ff?-T33 <br /> C-57 Contractor �I �6 RI&Lo j Address 150 110410 RD. City P1 RTLWL`Z- Lic Phone <br /> _Cons_ ul nUSub Cntr A-T6 Address 2S 6UPA-11} GI R. CityLic Phone( OS�e�y���Z�7 <br /> Billable Party ATG FOR COP Address ZS GVPAti/A G/R. Cit Zip *7�Phone(�S1 /96-/Z/7 <br /> GfS Coordinates.X 8. olC Y '•/Z/. 3z y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT.GE PROBE.HYDROPUNCH,HAND-AUGER,OTHER <br /> I &SOIL BORING IDs -' - OLC-Oity- TEM A 4 <br /> 6- ®WELL IDs__Ajb✓-L7_TO <br /> OTHER IDs - - --_-• <br /> TYNE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I <br /> iibs`V <br /> MONITORING ❑HOLLOW STEM DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA. <br /> _❑EXTRACTION Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS L '-/O TYPE OF CASING: ❑STEEL JKPVC ❑ OTHER �� <br /> —D SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL o r TREMIE TYPE TO BE USED ❑AUGERS El HOSE PIPE 1� <br /> J-k SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:14 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.AirSoaroe.ozone)❑HAND AUGER GROUT SPECIFICATIONS GFi*14e.✓j 690(17 <br /> _❑OTHER ❑OTHER. APPROX BORING DEPTH y Z6 0 r &tOLTED TRAFFIC BOX OR ❑STOVE PIP <br /> CONDUCTOR CASING XNo El Yes Casing Dia: Casing Depth Boring Dia <br /> COMMENTS:f[/LILLo►✓ IvELtf ?a �0 i QQr WdLLf 70 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 applicable California laws. 9 <br /> Signed Title/Company �n. a✓ �A��� -�T� ASSoG�AT�s <br /> Print Name �/✓ G Il�1i1- ✓z� <br /> Date 12� 3Z/I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS T(y <br /> NORK PLAN DATED 2-- / <br /> APPLICATION ACCEPT DATE SU 3�� Z AREA�� <br /> GROUT INSPECTIO BY i FINAL INSPECTIO DATES /.2 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: --/lj 0 <br /> ACCOUNTING ONLY. AID# q 1 Z�r ^� <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SER CE R INVOICE <br /> / REQUEST EPR# <br /> 5o I <br /> $ 122. (p O, ' SR#O <br /> 3 00 > <br /> v# Q� Z <br /> C-57WC _ _WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENTDriC <br /> EH—, 29-0'! 07/28/10 <br /> W LL PERMIT APP <br />