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SAN JOAQUIN COUNTY NI L C <br /> LOP <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> • �' '' Telephone:(209) 468-3454 Fax:(209) 468-3433 Web:www.siaov.org/ehd <br /> 1 Sri=oa`'• <br /> WELL & BORING PERMIT APPLICATION CEIVED <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDI <br /> ' NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AU� 0 5 2011 <br /> Application is hereby made(o San Joaquin County for a permit to construct and/at install(he work described. This application is made in comp lance with San <br /> Joaquin County Development Title,Chaplet 9-1115.3,and,The Standards of the San Joaquin County Environmental IHeallh Department. <br /> Site Location ZSOO 5.'r/u�'/ Cross Street \/ta'L- PI C-0 city %_/ ._b�t�/ zip 953�1�� PN:2.`/6•/gDD9 <br /> Propertt•/� —7 L / <br /> Owner C/T 07�,Z.la�_- , . _ Address, ,/0-22 - /�CitX 7ip 95..-3�. .)onel//7l�o, y�/G SZ-yam <br /> C-57 Contracto Lvbe - A. �rAddress 9s�ta CarHyi/ % City orz, Lie 29333-&Phonq kL9-73 36 -3 <br /> Consultant/Sub Cnfrir/�i,- cv�C�Ir�address <br /> , Phonel3/ SSt$ <br /> Billable <br /> S-V4/VZ Cily/0'7�1G�7- Zip 31 tJV/ Phony o/V Gs2-�/a5a <br /> GIS Coordinates:X Y <br /> ' CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs - <br /> ' ❑OTHERIDS - <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE _❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA' <br /> ' _(]EXTRACTION Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING 0 STEEL 0 PVC ❑ OTHER <br /> _Ej SOIL VAPOR PROBE (3 MUD ROTARYDEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS ❑HOSE ❑PIPE <br /> ._O SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED 0 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ■VAO� <br /> _O INJECTION( Air$par e O ne 0 HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER. _ 0 OTHER APPROX.BORING DEPTH Cl BOLTED TRAFFIC BOX OR 0 STOVE PIPE. <br /> CONDUCTOR CASING 0 No 0 Yes:Casing Dia; Casing Depth __ Boring Die._ <br /> COMMENTS:_ _ <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED:/..�/,-Z``/-9 /x"57 DESTRUCTION METHOD: CHECKALL THATAPPLY (� <br /> / #oF WE LL(S)TO BE DFBTROYED,v�=5-'/dG--•�' dG/y �G%$� OVER-BORE DIAMETER OF INCHES TO DEPTH Or^ 13 FT <br /> WELL IDs:/sG-/8' ,BG/9 G`- / <op�GrJ'''L G3C�/3 ❑PRESSURE GROUT TO DFPTH or FT OCLOIV SLIHFAO[ <br /> ' GROUT SPECIFICATIONS EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE/TO BE USED: AUGERS ❑H SE ❑PIPE / p MUSHROOM CAP AT L3 FT) FTBCLgW SURFACE <br /> COMMENTS(TrOG.�` L.�%f�Ftil 7�7�G�.�?S oYSU--/,EL wrap/�J/G SlirfeG<�.r C. <br /> RKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> ' I ereby certify th I have prepared [his application and that the work will be done in accordance with San Joaquin County Ordinances, Rules <br /> Reg ions,and all plicabte Calforn' aws <br /> Signed ` _ -�O'���/ Tille/Company <br /> Print Name ,GTeA/!il /t7 'VO// _ Date <br /> ' DEPARTMENT USE ONLY C7✓eeur�e`y GG/.z r <br /> SITE MAP IN UNIT IV FILE-SITE ADDRE`�S S it/. Va-t ' <br /> WORK PLAN DATED (o�hr-'if _' _APPLICATION ACCEPTED BY _ .. _ D \9L <br /> GROUT INSPECTION BY > FINAL INSPECTION n _ __ DATjrt <br /> ' DESTRUCTION INSPECTION BY -_-___ - _ _ DATE .- -_ _ �T� IN <br /> COMMENTS/CONDITIONS: +w <br /> ACCOUNTING ONLY Air)# I-AC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY SERVICE RD# <br /> DATEROUINVOICE <br /> QUEST f <br /> PR# <br /> S,122X -!-5- _ SRA 0/03IR1 <br /> _ __. <br /> ?-5-/1 <br /> z9 o)O$0650 _ <br /> t C57LEEROFAUHlN0 -_- _ D <br /> EHD 2941 07'28 10 y WE�LL PER <br /> MI-T_APP <br /> OW ell <br /> OO <br />