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oAQ�IN SAN JOAQUIN COUNTY F CEIV <br /> E '' <br /> r : ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> ' 600 East Main Street, SITE MITIGATION <br /> Stockton, CA 95202-3029 i <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 W UNIT IV <br /> q<%F ORN�P <br /> �.11'�tYdl�,ou otaLell� <br /> WELL & BORING PERMIT APPLICP NRVIcES <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 th <br /> e Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 2103 Navy Nv( Cross Street !c C Yr+ /� °! <br /> Property 11 --� � City r Lrt7oY� ZiP APN I� - 3� 26- DDL <br /> Owner Ooyly TakdO Address Jags MesSW."d ,Cit FSlQId-YI <br /> C-57 Co trac€or _ e � Address _ ^/rQ y ZI17_415 .t'=-Phone X09-9y?-/7 7 <br /> A �� �T [ C� �A- Phone A/ —� <br /> Consultant/Sub Cntr Al Aff_* )*W'A6dress (l/7 Le•�t Pmts. A,,u �r�47 Llc AVS—Phone)6'7-5779^)»l <br /> 1 crty_Mod�rfo Lic�'._L <br /> Billable Party � � �N�fMrTr•w) Address _.7 yuT /1/•�-fir }7"-4- City 5;4t44*K Zip 9577[16 Phoned 1-ty7-/77' <br /> GIs Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED- <br /> NEW WELLIBORING(CPT,GEOP OBE,HYDROPUNC HAND-HUGE THEIR)�I SOIL BORING IDs�f <'(� g <br /> (]WELL IDs <br /> ❑OTHER IDS <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLEr N/G <br /> �—El MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _ <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS D 1031 in 116 STYPE OF CASING: ❑STEEL ❑PVC% OTHERTZ sn Tulin <br /> IVSOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL964't' <br /> _TREMIE TYPE TO BE USED: ❑AUGERS 0 HOSE El PIPE <br /> _O SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION ae AirSpargeOzone)KHAND AUGER GROUT SPECIFICATIONS Nt.+ W-1"+ <br /> _0 - <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 'I' `BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING/0!�No[3Yes:Casing Dia: Casing Depth:_ Boring Dia: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD rcHECK ALL THAT APPLn <br /> _#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF <br /> WELL IDs: ❑ FT <br /> PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS El EXPLOSIVES FROM TO FT BELOW SURFACE <br /> CO MIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE [I 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 /> Reg ulatio�n/s,/Ind II plicable C�Iifor "a laws. r� / <br /> ✓v Title/Company Pf!! ee4 6,(D1df/f"� //jT� dC/�7�S�n( <br /> Signed Q c� / / <br /> Print Name �a"�Aa.e [-!/r V7�4V\ <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS a y� <br /> qd7 ' r 4 1 7 <br /> WORK PLAN DATED 6C_ A ` <br /> APPLICATION ACCEPTED BY DATE ISSUED /0 AREA?97 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE/f 0 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: 3 V 4 S6' <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> _ s REQUEST PR# <br /> $122, / Z7i- tv c // SR# 0/0%l 10>` <br /> Xoy >ue, (G r, v R 00 / <br /> /07 <br /> PR# <br /> (2900 <br /> C-57-^ WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />