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Op4H!N_ L. SAN JOAQUIN COUNTYaR <br /> , <br /> .oma I 'SOP7 <br /> ENVIRONMENTAL HEALTH DEPARTMENT ,y_ <br /> t-.0 0\� SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> UNIT IV <br /> Telephone:(209) 468-3464 Fax: (209)468-3433 Web:www.s' cty or l � p� /� <br /> /FOR <br /> WELL & BORING PERMIT APPLICATION <br /> C R V <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATJP,1 2 9 ZU)) - <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED W LD• <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application rdftN0N<igE1911 T LS ' <br /> Joaq evelopment Tate,Chapter 9.1115.3,and the Standards of the San Joaquin County Environmental Health Departt *MIT/SERVICES <br /> o• <br /> Site SWC �G'��/G� Cross Street 7r- .jc1 .j�VC� City ��Gtl Zip�S3��o APN�y//pO�/008_ <br /> Props,rt`•,,/ [� � /3 y—�/ n' I Ci _ Zip PhoneWae�Sy$03 <br /> owner /�l�d.i�-�rraC�.Gfsriv.�is,� Address w l �Y <br /> C-57 Cnntractor/<-�' Address5 'M C�^"�"��� CdY D,�l� Uc Z 8s3Z6 Phone�u�r!/ <br /> ConsultanUSuh Cnt/M/c� o ✓ Address �S3u3�t Z9G 4 707 <br /> City !/i//3 / Lic UDUg Phorge//)939-9s.Sp <br /> Billable Party�T64T -a�Ir-lGd�i�c Address y.Zi+c�+7'i^e�. /V� City/�f�a�7� Zip 63.x_Phone�Ydji,1/o -�/G/�� <br /> GIS Coordinates:X -3T•�lrj Y -IZ�• <br /> CONSTRUCTION WORK TO BE PERFORMED: ' <br /> ❑NEW wELL/BORING(GPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs Lr <br /> ❑WELL IDs l4 <br /> ❑OTHERIDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN 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(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 Fn <br /> _Q INJECTION 0e.Air Sparge,Ozones❑HAND AUGER GROUT SPECIFICATIONS <br /> _ _❑OTHER: ❑OTHER: APPROX,BORING DEPTH 11 BOLT <br /> TRAFFIC BOX OR El STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth:_ Boring Dia: <br /> JMMENTS.. . <br /> NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHODCHECK ALL THAT APPLn <br /> �j #OF WEL�LS�TO��_�BGGGGEyyyy DESTROYED OVER-BORE DIAMETER OF�-_INCHESTO DEPTH OF�FT <br /> WELL IDs: �'�� / `-'� �PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIO S GL [3 EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE T BE USED: AUGER❑Z S EGA O ,. /• .�MUS ROOM/CAP AT >3 FT}rZ r T lv OW RFACE <br /> COMMENTS /-1tLs,�' �Y� 7K /=1cf.. •fY <br /> 6 ORKING DAYS NOTICE REQUIRED (eFTER PERMIT ISSUANCE) FOR INSPECTIONAPPOINTMENTS <br /> I h eby certify at I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regu ons,and I applicable Cali la law C <br /> Signed ka Title/Company/�G7�Dr!• ✓�/ % %✓'DN // // <br /> Print Name �'✓�✓�/•f /�� S Date <br /> DEPARTMENT USE Or�NLY lUA: <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS S W At- rICO �C�'29:F� <br /> WORK PLAN DATED IjMIAQ IIc� <br /> APPLICATION ACCEPTED BY D�AaTE[ D ���J^ZoLt DATE:Ala�66�g <br /> IN <br /> BW <br /> GROUT INSPECTION BY <br /> FINAL <br /> DESTRUCTION INSPECTION BY_ _ DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: ,AID# FAC# <br /> SERVICE RO# INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK* RECV'D BY DATE REQUEST I PR# <br /> 29DL > g122X3 SR00016140 <br /> • " $ Cr, •2Y- i <br /> PR� <br /> Z4b3 311.E 3b(o zaoa <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT E <br /> WELL P RMITAPP <br /> EHD 29-01 07/28/10 ait-elIQ& <br /> ^ ^ 44 /AT <br />