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SAN JOAQUIN COUNTY <br /> (a. <br /> ENVIRONMENTAL FIEALTH DCF'ARTMENT SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV " <br /> tone: (2.09) 468-3454 Fax: (209) 468-3433 Web: www.sjcgov_2 /el)tl- <br /> WELL & BORING PERMIT APPLICATION <br /> AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEbIAtioN <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 conipliance 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 /!' f}�l !(. f�lr Cross Slreel n I 1�A Z I` City 7/y''A lJ t zip_ <br /> �1�yt'•1t,fi,., <br /> V-Owner �Lay4lif E�N/tLlf'� Address D j fS0+P k111 City I& s +f`,ti it Z Zip 1. -': _Phone[U)5S L� <br /> C-57 Contractor 1 Address i I,a 5o''fp,V!(,lZ � j�, _ <br /> City '� _Lie �D b _Phoned _ <br /> Consultant/Sub Cntr �` TG Address - d yA^'t,9 t 1'GL City —Lie --Phone �s')y 9�-rZ J - <br /> Billable Party�,/ �Of; �i� Address I i Ute �tr1 GIRIL1_ta city��ju 4- Zip /7.75 PhoneL 00S�N�; ILL : <br /> GIS Coordinates:X Y—-W•% ''II <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> 1'9 NEW WELUBORING(CPT.GEOPROBE,HYDROPUNCI-i,HAND-AUGER.OTHER) <br /> ❑SOIL-BORING IDs _.--- -- -- -- — <br /> ❑WELL IDs - -- -- <br /> [WOTHER IDs _( i• Y-� : 7 PoI J tY ['!L 1/rf 'j( F'i�y —TYPE&N OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING U HOLLOW STEM DIA,OF BOREI IOLE ❑MULTIPLE CASINGS[I MULTI-LEVEL WELL CASING DIA <br /> _❑EXTRACTION.Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING. ❑STEEL ❑PVC ❑ OTHER <br /> ZIq SOIL VAPOR PRO13F ❑MUD ROTARY DEPTH OF GROUT SEAL -> _TREMIF TYPE TO BE USED- ❑AUGERS ❑HOSF ❑PIPE <br /> _❑SOIL BORING 11 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes LF]"No,MAXIMUM FREE FALL DEPTH IS 30 FT) �t t <br /> _❑INJECTION(,e.Au SparcleOzenel❑HAND AUGER_- GROUT SPECIFICATIONS <br /> _Q OTHER" ❑OTHERAPPROX.BORING DEPTH ✓ ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CAS NG O No,�Yes:Casing Dia:_ Casing Depth: Boring Dia <br /> COMMENTS: 7 �1I�O�fRY yet- 1/AY�R t�� ni}Y-5e��fo��) 5. Yfr/ OF !-vS"��l�_, !/L�✓ <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> _DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPY) <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 0 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 a piicabfe California laws. <br /> Signed � Title/Company _ T71t LT ,4'y4 6 A TL <br /> Print Name t�G G _ Date__L <br /> DEPARTMENT USE ONLY , <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEP'rED 6 _ DA" - IS ) U�bi�f <br /> GROUT INSPECTION B�'// — -"-- FINAL_INSPFCTI DATP= <br /> `,. " <br /> DESTRUCTION INSPECTION BY _ DATE <br /> COMMENT-S/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE 68 <br /> 1117-CODES FEE INFO AMT REMIT fED CHECK# RECV'D 13Y DATE INVOICF <br /> _ REQUL-Sf P fI <br /> 350 5 I 1 Z5.'-- /I l -- - Liu? 1� �..lD�/Z sRrlD MP3 <br /> s00 55 -- --- <br /> V WG — 1NAIVIcI� -- _ ( -97 LETTER OF AUTI-IOHIZAIION TO SIGN PERMIT ( k=PICt7UAraIMFNT Dc)C; <br /> PI- <br />