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ORIGINA !_ <br /> C tj I SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SIT E MITIGATION <br /> 1868 1 Iazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> Telephone:(209)4683147 Fax:(209) 4683433 Web:www.sij-qqy-0-r9-1eh <br /> WELL & BORING PERMIT APPLICAT ION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLENON-REFUNDABLEPERMIT--EXPIRES-']-YEAR FROM DATE ISSUED <br /> - <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 o an <br /> the S i .n County Environmental Heallh Department. <br /> -213 <br /> " <br /> ZjpESI?30 APN Z,13-310-i' <br /> Site Location-L-.�-- Cross Street C­mccc,al /S a LA2-4� i 97-1-7q <br /> Property Phone <br /> Owner I�ivc-T',Ibn�f, -1,),4.t4,,,,�t-iS-Address '3,K &-, Cil (State Lvll,,,:,�-CMPIC1��90 <br /> . 0 Ck- 4 Phone Zo"-H 69 ---M <br /> City/Sfate!S&a- -1 <br /> ov <br /> C-57 Contractor '\/.q- ',,/ 12,1 Ln�,_ Address :SESO L C)", kj-�-jg'4ic- <br /> Consultant!Sub Critf_C- c, City/State-Cp r) Lic!,`tom( ---Phone 9, <br /> LL_F o Address SlBc�' f-) <br /> Billable Party Fr/6 E-c) Address :fflQ IA Ql"� City/State -_71p PtLone?on,83SE-2(,- <br /> y -('4 1,J <br /> GIS Coordinates:X L--?.,Tj I s�B0 I CNf Iv/? <br /> CONSTRUCTION WORK TO BEPERFORMED: <br /> EI NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> El SOIL BORING IDs <br /> ❑WELL ID <br /> ❑OTHER IDs- <br /> TYPE&#OF WELLMORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING [I HOLLOW STEM DIA.OF BOREHOLE — 0 MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA: <br /> -I- E)Pvc [A OTHER <br /> CASING THICKNESS _TYPE OF CASING: []STEEL[I HAMMERfORIVEN -]AUGERS El HOSE 0 PIPE <br /> 0 EXTRACTION:Vapor/Watur TREMIE TYPE TO BE USED: L <br /> --EI SOIL VAPOR PROBE [I MUD ROTARY DEPTH OF GROUT SEAL_ <br /> SOIL BORING El PUSH POINT(GPI CPT) GROUT SEAL PUMPED:El yes []No(MAXIMUM FREE FALL DEPTH IS 30 IFT) <br /> IN,)ECTION 0 HAND AUGER_GROUT SPECIFICATIO14S OR [3 STOVEPIPE <br /> -E]OTHER: El OTHER- APPROX.BORING OEPTI I [I BOLTED TRAFFIC BOX <br /> CONDUCTOR CASING[]No C]yes:Casing Dla:—C051RU Depth:— Boring DI <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRIJC71ON METHOD: CHECK ALL THAT APPLY) <br /> 'S,OVER-BORE DIAMETER OF '0 .. NCHESTODEPTHOra-A <br /> #OFWELL(S)TO13E DESTROYED _2- ❑PRESSURE GROUT TO DEPTH OF - ®FI <br /> BELOW SURFACE <br /> WELL IDs: I ❑EXPLOSIVES FFIOM__-------jO- FT BELOW SURFACE <br /> GROUT SPECIFICIONS- C­ cr-,a. U MUSHROOM CAP AT L>3 FV)_I--r BELOW SURFACE <br /> TREMIE TYPE TO BE USED:El AUGERS U HOSE PIPE <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 Wills San Joaquin County Ordinances,Rules an <br /> Regulations,and all applicable California laws. - - - 6 F-(�7 <br /> IFICf-d lec-F <br /> Title/Company eo <br /> Signed <br /> Date. I <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> 'n - b <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS & 8 <br /> WORK PLAN DATED 5, �e�41 <br /> 0 OKU ryl DATE ISP 4f 4�-/Lf AREA /69q <br /> APPLICATION ACCEPTED BY FINAL INSPECTION BYPt I DATE <br /> GROUT INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> FAC# <br /> ACCOUNTING ONLY_­ RO I$ <br /> — : AID 1t­-­.­— DATE -SERVICE INVOICE <br /> KPECO:DE;S; FEE INFO AMT REMITTED CHECK# RECV*D BY _EEQ!IF�-ST PR#_ <br /> SRfl <br /> 08 $130X RON <br /> �96 'I e,C) <br /> PR 11 <br /> PERMIT ENCROACHMENT DOC4 <br /> --- ERO K <br /> C-57 v� WAIVER A,1A C-57 LETTER OF AUTHORIZATION TO SIGN I <br /> WELL PER I PP <br /> PI-ID 29.04�7124 i4WC <br />