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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stockton, CA 95202-3429 SITE MITIGATION <br /> Telephone: (209) 468-3464 Fax: (209) 468-3433 Web:www.sfaov,oralehd UNIT IV <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct andlor Install the work described. This application I$made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards oftheSan Joaquin County Environmental Health Department. <br /> Site Location 1161 IQ W 166ti Vlti yCross Street City S 6k b 1) Zip APN 117,0g0,1g0,0 <br /> Property,,,,,,Aritr6�Qt�tl61ZIk 61 edPOa� Address �� BOX 29oyb city,fti0Cr1/X ,AZ Zip $5038 Phone 60 'Zb3'6555 <br /> C-67 Contractor Address-A 2 QQ16C 6. 61P, Citybaho CcydotiJQ.IALIc q38 I/O Phone %6,639. 169 <br /> consultanusub cntr C ASsixra c Address 4185 51084 FQrrdCf Xe "01 city rmpe , ZZ L I c 75564 Phone 00.3Z,'050 <br /> 61liable Party ATC ASSd ciA kS INC. Address aA ci b0 J 2, y Ip Phone <br /> GIS Coordinates:X 37a 9'06,01 r Y - atr Ifi 11'K"- <br /> CRNSTRUCTION WORK TO 5E PERFORMED: <br /> NEW WELLA30RING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ®SOIL BORING IDs 58-1 and S4S•Z <br /> D WELL IDs <br /> D OTHER IDs <br /> TYPE 8y#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _D MONITORING Iffi HOLLOW STEM DIA.OF BOREHOLE 6" El MULTIPLE CASINGS O MULTI-LEVEL.WELL CASING DIA <br /> _❑EXTRACTION:Vapor/Water E)HAMMEIVORNEN CASING THICKNESS _ —TYPE OF CASING: ❑STEEL ❑PVC O OTHER <br /> ._O SOIL VAPOR PROBE O MUD ROTARY DEPTH OF GROUT SEAL 5'6O_TREMIE TYPE TO BE USED: 19 AUGERS ❑HOSE O PIPE <br /> Z C4 SOIL BORING [3 PUSH POINT(GPICPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _E)INJECTION neRrSoarae-ozonel0HAND AUGER GROUT SPECIFICATIONS Porkland 1�C I/// <br /> __t7 OTHER: - CIOTHER:__ APPROX.BORING DEPTH SS�O r ❑BOLTED TRAFFIC BOX OR CISTOVE PIPE <br /> CONDUCTOR CASING®No[I Y03: <br /> Casing Dis: Casing DeP011 Boling Dla: <br /> COMMENTS:SB I So rl bOrino IO $S'0Q4 A1i0J6 (11g1Gr� SB'� .w' �0/(ro M 60,(N S�rn ly walc✓). <br /> NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION TO BE FERFORMED; I:ST CTION METHOD:(CHECKALL7HA7APPLYI <br /> #OF WELL(S)TO BE CESTROYED OVERBORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: D PRESSURE GROUT TOCEPTHOF FTBELOWSURFACE <br /> GROUT SPECIFICATIONS D EXPLOSIVES FROM 70 FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:D AUGERS HOSE D PIPE D MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby cortlfy that I have preparod this application and that the work will be dono In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,an Ilpl &e California Laws. <br /> Signed Tltlo/Company.,ni0( &jecf Mar>aq,-1,97C Asso06,ks I/4. <br /> Print Name Date 3l/3�l2 <br /> DEPART ENT USE ONLY <br /> SITF MAP IN UNIT IV FILTE ADDRESS -�n 0 1 M + w <br /> WORK PLAN DATED I/ <br /> L" LIJ APPLICATION ACCEPTED BY DATE ISSUED !Z AREA <br /> GROAT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# INVOICE <br /> PEE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUES�T/ I PRN <br /> 7St�� S 125 x �� __-- SR# T7 / <br /> 31 9 � .� RO# <br /> 3-7 <br /> S�3 � d _- 3500 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC <br /> /�"D3gZ7 <br />