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L1 ul.= i.,—u \./ L�_�I=/ <br /> OCT 1 9 2010 <br /> FILE COPY <br /> 11tH ; HEALTH SAN JOAQUIN COUNTY <br /> N' { 'ERVICES ENVIRONMENTAL HEALTH DEPARTMENT nr=LQRI�Ii�I lr,�l� <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> a. Telephone:(209)466-3454 Fax (209) 468-3433 Web:www.siaov.orglehd <br /> UNIT N <br /> a:.F <br /> WELL 8r. BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NDN-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 CountyDevelopmentTito,Chapter 9-1115.3,and the Standards of the San Joaquin Cgunty Environmental Health Department. <br /> Site Lo-cation 01 C <br /> 0. SaA'&i �A. Cross Street h Co. City�Dz_icli Zip APN 135Z-60b <br /> Property_ ,J 'i�CE+� <br /> Owner TDC St7 Address L4'53 VHAm*Da--city�T�C mfq Zip Phone <br /> C-57 Contractor tI of, Address City I t(ir{ll 1GZ Llc ~l Phono M 13) -5 <br /> Consultant/Sub Cntr '—PUS Address tC�M LZs�lut 5 City�Al't FarriV�Lie Phone 37q- --7q� <br /> Billable Party -:(,w '-g, Address j(D M4DT0q_ City 5t1 &LD ZIP q.q 10 J_Phone � J — <br /> GIS Coordinates:X: 37.`?T� <br /> CONSTRUCTION WORK TO BE PERFORMED: ! <br /> ANEW WELUBORING(CPT,REOPFROBE,HYDROPUNCH HAND=AUGER.OTHER) <br /> f�SOIL BORING IDs (Pr— r_9 <br /> ERWELL IDs )4 }-J <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 4 (� -LEVEL WELL CASING DIA: <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE _ _❑MULTIPLE CASINGS❑MULTI <br /> _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER_ <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ❑INJECTION fte,Al15na1qe OzoneHAND AUGER GROUT SPECIFICATIONS <br /> —❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING 171No❑Yes: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: DESTRUCTION METHOD-(CHECK ALL THATAPPLY1 <br /> #OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCITES TO DEPTH OF FT <br /> WELL IDs: E]PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATION$ ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:[]AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L>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 application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all a p:cable li nl laws. j <br /> Signed Titre/Company / /,9 <br /> Print Name ") —Date _ <br /> DEPARTMENT USE ONLY Z� �(5/c <br /> G�R-W Q� <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS �l NCL <br /> • . <br /> WORK PLAN DATED - 3 2-01U' <br /> APPLICATION ACCEPTED BY DATE ISSUED D—L 1 b AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE Q <br /> COMMENTS/CONDITIONS: i <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> Zq 0 I $122,, 4 -f'16 8 SR# 0613zs <br /> Z b io Iq ZOIC flea5l83 <br /> 2Ra 5 122. X1320 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br /> EHD 29-01 07/26/10 l.ft,14-1> WELL PERMI APP <br />