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sae°u'0 lbSAN JOAQUIN COUNTYEr.✓IRONMENTAL HEALTH D R LOP <br /> SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 952'02-3029 r 1 1�14T <br /> ;•./..sRa� Telephone:(209) 468-3464 Fax: (209)468-3433 Web:www.s' ov. r C[�7 <br /> WELL 8t BORING PERMIT APPLICATION' ��� 9 2011 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REME IA ION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicationlr?(yli►pW with San <br /> ' Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department <br /> -07 <br /> Site Location FSA), Cross Street 7;-a4Cy ,6/vee City rr zip�.S3 o APN��Io/3aag <br /> Proper"•/) C� IyC _ p / 1 d <br /> Owner f'C _ Address�6atJrfieG S�./✓E City 122'14,1'h- Zip3�.,35/p Phone4g6 /rI5'Z-VA6,6 <br /> ' C-67 Contractor!//bGG eo'tAddressl5`s'O�t„ �e>!9-3.B Cityrd✓a.- LicZS33z& <br /> lib vas sfiiivL✓ o o Phone 81-713-36i;' <br /> $�3-3d <br /> Consultant/Sub Cnt�/ek� o. �r ✓ Address �`S33e3.,S/t vz90 City �i/�/ Lic �S Sd Phorla�//i�937�SS� <br /> Billable Part enT a..�itGiric- AddressY Chy�fIa,1 � Zip3�y� Phone,/- <br /> GIS <br /> honeG <br /> ' GIS Coordinates:X "S7. 113 Y--I zi. 1Z(E <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HVDROPUNCH,HAND-AUGER,OTHER) <br /> ' ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS . <br /> — <br /> ❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ' _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) r <br /> —❑INJECTION 6.e A4 Soarac Ozone/❑HAND AUGER GROUT SPECIFICATIONS <br /> —❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE A <br /> ' DMMENTS: CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth:_ Boring Dia: �i <br /> NOTE: OFFSITE WELLS 4 BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BEPERFORMED://S-1,.JS-2/ 33/9Y-VDESTRUCTIO METHOD:ICHECK ALL THAT APPLY) <br /> ' L.#OFW LL(SJ TO BE D STROVED S-'S/�$'�O/flS--�/ S•d/�S.L� OVER-BORE DIAMETER OF INCHES TO DEPTH OF- T� FT <br /> WELL IDs s%Di/�S/SNS/ . G-!n_ zrra-Z' Avv ZL/Ono J, PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFIATIONNS f✓ - Gs ryt 7` ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE UST AUGERS ❑HOSE ❑PIPE MUSHROOM CAP AT(>3 Fr) FT BELOW SUgFACE <br /> COM dro�7` vi7fi4n. Z Go.+� ur scYG1� <br /> 5 WO ING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> ereby certify that ave prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Re tions,a d all a lloable Calif ws. <br /> ' Signed Title/Companyl-4-7k !/yl/ SO✓I-�//✓/,>-O/4/flGrl ,�.,/'1 <br /> Print Name Date_- / <br /> ' SITE MAP IN UNIT IV FILE-SITE ADORES DEPARTMENT USE ONLY .- w <br /> WORK PLAN DATED I <br /> ' APPLICATION ACCEPTED BY DATE S UE r 3' I I AREAQ/y��'r�� <br /> GROUT INSPECTION BY FINAL INSPECTION BY CATFJ � <br /> DESTRUCTION INSPECTION BY DATE <br /> ' COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVI <br /> REQUESPR#CE RO# INVOICE <br /> T <br /> 1 2rJo2- $ X !� 195z. 18680 Gtr 7Z - i/ sR/ 16�/ <br /> 2318°° I <br /> 2`103 3 36� leb ira z9 o asobs <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> 'EHD 29 OI 0726/10 WELL PERMIT APP <br />