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SAN JOAQUIN COUNTY <br /> a' n ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> :• 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> `�.,. Telephone: (209) 468-3454 Fax: (209) 468.3433 Web:www.slgov,org/ehd UNIT IV <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 4 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct andfor Install the work described. This application Is made In compliance w(h San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards 0(thelSan Joaquin County Environmental Health Department. <br /> Site Location ?101 !v W,Ls6/1�_ Cross Street N $RtQVi,74A Ln City S ckh Zip q, 205 APN 111.080.1 -0 <br /> Property p / �r <br /> Owner Wilma,Ped(zkk COrH�r� Address Pro BOX 290q-6 City /f Zip 85038 Phone 60-4$-6S55 <br /> C-87 Contractor Address'i 2 0alec 6ldf Clty P&ICAO�Llc 439110 Phone T6.639.110 <br /> Consultant/Sub Cntr CASSX6 C Address V15 540/4 h6ffff M '/Il City T rnlOG j Rt Lic 75S66Phone 001ZAb$O <br /> 13111ahie Party AZ Assd cjA,l s rnC. Address 4A a 604 e, ZIp Phone " <br /> GIS Coordinates:X :37°SA'Q4,Q I" Y 121 1611`I 30" <br /> CqNSTRUCTION WORKO BE PERFORMED: <br /> 29 NEW WELLJBORING(CPT,GEOPROB£.HYDROPUNCH,HAND-AUGER,OTHER) <br /> ®SOIL BORING IDs 58-1 and SS•2 - <br /> D WELL IDs <br /> 0 OTHER IDs <br /> TYPE 8y#OF WELIJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _0 AtoNITORING Iffi HOLLOW STEM DIA.OF BOREHOLE C�rt ❑MULTIPLE CASINGS C,MULTI-LEVET.WELL CASING DIA: <br /> _0 EXTRACTION:Vapodwaler ❑HAMMEWURrVEN CASING THICKNESS `TTYPE OF CASING: 0 STEEL Cl PVC O OTHER <br /> ❑SOIL VAPOR PROBE D MUD ROTARY DEPTH OF GROUT SEAL 55 60 <br /> 7__TREMIE TYPE TO BE USED: 0 AUGERS ❑HOSE O PIPE <br /> -2:-00 SOIL BORING ID PUSH POINT(GP/CPT) GROUT SEAL PUMPED-.,W Yes 17 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> -0 INJECTION(1.9.Nr Soame Dione)0 HAND AUGER GROUT SPECIFICATIONS P04141nd IV44 1/11 <br /> ,—[D OTHCR: D OTHER: APPROX.BORING DEPTH S5 _,6D I 0 BOLTED TRAFFIC BOX OR d STOVE PIPE <br /> CONDUCTOR CASING®No❑Yes:Casing Die: Casing Deplh: Baring Ota: <br /> COMMENTS:SS-i So I/ 190rrnaA 55'0241004 Wilk:) S8.2 sn/1 hollna h 60' $'rn% watt✓} _. <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORME DESTRUCTION METHOD: E KAL P <br /> #OF WELLS)TOB[ DESTROYED OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FTBELOW5URFACE <br /> GROUT SPECIFICATIONS 0 EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:O AUGERS HOSE 0 PIPE I]MUSHROOM CAP AT(>3 FT) FT 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 dono in accordance with San Joaquin County Ordinances,Rules and <br /> c, <br /> Regulations,an II a I ble California Laws. <br /> 9 PA <br /> Signed Title/Company �eIflO/ P/d//tf Man�rrq<i/f11L" t9S.SOCIQ.�IS �!)c. <br /> Print Name GiltF�u- Date'11v311,3112, <br /> DEPART ENT USE ONLY <br /> SITE MAP IN UNIT IV FIL TE ADDRESS -�n 0 N + bU-JAD� w <br /> WORK PLAN DATED / <br /> APPLICATION ACCEPTED BY SPECTIONOAT SSUZED ( AREA <br /> GROUT INSPECTION BY FINAL INBY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: _ AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV•D BY DATE SERVICE RO# INVOICE <br /> REQUEST/�PQt2# <br /> 3SoS $125 x �� Y> �D SR# T 7 / <br /> SD3 ti�z& 3- 0ie Ro 0) <br /> PR# <br /> 2900 <br /> 0-57 WC -WAIVER. 067 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />