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� U � <br /> SAN JOAQUIN COUNTY I <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> ' 600 East Main Street,Stockton,CA 95202-3029 SITE MITIGATION <br /> hone:(209)468-3147 Fax:(209)468-3433 Web:www.slaov.oraleh UNIT IV <br /> OWELL 8t BORING PERMIT APPLICATION <br /> WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applcalo hereby made to San Joaquin County for a permit to construct andfor instal the work described. This application Is made In compliance wth San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department <br /> Site Location ���S Cross Street L�l�" L 5 City ly'�S"1A -F= Zip15L) APN 19� <br /> Property, " <br /> _ ^6 <br /> Ower �O �A^LSti6vAddresslt( 10YU0dOccity GreAZip ciSPhon <br /> C-57 Contractor Add : A= city SA Orq AA, 0 Lie 335�1Phm;(96 <br /> � <br /> ConsultantlSub Cntr Address CI� S' )n Lie a� Phone 07 ?3 <br /> BlBable Party Address 1,Y) 571' d Ci 1C V\ Zip_q 15' Phone C� S1�170U <br /> I <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELUBORING(CPT.GEOPROBE•HYDROPUNCH,HAND—AUGER OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING0 HOLLOW STEM DIA,OF BOREHOLE_ MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _O EXTRACTION:Vaparl Water 0 HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER - <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> _O SOIL BORING 0 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) - <br /> _O INJECTION po Alrsoeme.0 HAND AUGER GROUT SPECIFICATIONS <br /> _O OTHER 0 OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING 0 No 0 Yex Casing Dia: -- Casing Depth:_ Boring Dia:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUC ON METHD• ALL THAT APPLY) <br /> , r <br /> #OF WELL(S)TO BE DE ROYED OVERBORE DIAMETEROF � O 1NCHESTOOEPTHOF 2 FT <br /> WELL IDS:,,4�/tj�� .Au AAN5� ! ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS 4 I or c rrt- !' c ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERS ❑HOSE PIPE 'FtIA ❑MUSHROOM CAP AT L3 Fn F7 BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> 1 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 Il appllcablcl Callforate laws. <br /> Signed TltielCompanyyfCUh / p <br /> L <br /> Print Name &A-, NAAi�lnIXhate T-- <br /> I ate )ate )Q 1J— <br /> QEPA MENT U E ONL <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS S S" <br /> WORK PLAN D ATEO Z LZ <br /> APPLICATION ACCEPTED BY DATE ISSUED V <br /> GROUT INSPECTION BY FINAL INSPECTION BY DAI <br /> DESTRUCTION INSPECTION BY DATE ENVIRONMEN IAL <br /> COMMENTWCONDITIONS: LTH <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'0 BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> a7 $125X SSD" 3f8� (o I Iv SR# 004Is881 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> FHD29-0i 01113112 WE-LPERMITAPP <br />