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ENVIRONMENTAL HEALTH DEPARTMFN CA-lop <br /> SAN JOAQUIN COUNTY <br /> T <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> I elephone: (209) 468-3147 Fax: (209)468-3433 Web:www.siqRyo <br /> r lehq UNIT IV <br /> WELL & BORING PERMIT APPIAGATION <br /> FOR WELLS AND BORINGS USLD FOR CONTAMINANT INVF-13TIGATIONS AND REM17DIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance With <br /> Joaquin County Development Title,Chapter 9-1,115.3,and the Standards of the San Joaquin County Environmental Health Department. ),36-- 1705!�o <br /> Site Location 544 C. 1//h 51 (A <br /> Property Cross Street CA157T '5TP-C�� City/State TC-A(-� zip 1534 L APN 2-35 <br /> Owner Address ?;7'1 f- llh� <br /> Owner.TC 6&A LL' 5-r City/State li-2ACY CAzip 9S3A_ phone (qv&)ZqZ <br /> C-51 Contractor \AFOP- Ti=CH 5dA«Address 23tL -rr%?ASbi 5T. City/State i�p,DAPI 'Llic-UC8t; Phone( 1/5)37b C"115 <br /> Consultant/Sub C"tr?AtY,<A VIPP"Wd'�r'leLs-s )710 FP-Af4Y-LII,1 5T i-eZ:210 City/State OAel,A MALI, L1,11t. Phone <br /> Billable Party.PAII4AFA FtJ\/,rc;,;(JIVJTAkddress 1u10 VPAd1rLit4 SX, 0-700 City/State ----Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ja­NEW WELL/BORING(CPT.GFOPROBE,HYDROPLINCH,HAND-AUGER,OTHER) <br /> ?-,-- , lam' , Ll -7 1`4 <br /> 9,'SOIL BORING IDs i I i3rr <br /> E]'WELL IDs_ <br /> 0 OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _E]MONITORING [I HOLLOW STEM DIA.OF BOREHOLE El MULTIPLE CASINGS Ej MULTI-LEVEL WELL CASING DIA: <br /> —E]EXTRACTION:Vapor/Water El HAMMFR/DRIVEN CASING THICKNESS TYPE OF CASING: OSTEEL E]PVC [] OTHER <br /> _O SOIL VAPOR PROBE Ej MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS El HOSE 1 PIPE <br /> fg,901L BORING El PUSH POINT (GP/CP 1) GROUT SEAL PUMPED:[I Yes [I No(MAXIMUM FRF.F FALL DEPTH IS 30 FT) <br /> 7- <br /> -0 INJECTION(Le.Air Sparge,ozone)El HAND AUGER GROW SPECIFICATIONS <br /> n OTHER: lqbTHER:1),aGCT PUt24 APPROX.BORING DEPTH BOLTED TRAFFIC BOX OR []STOVEPIPE <br /> CONDUCTOR CASING CI No El Yes:Casing Dia:_Casing Depth:_ Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS_ <br /> DESTRUCTIONWORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> 4 OF WELL(S)TO BE DESTROYED El OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: [-]PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS El EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:El AUGERS Ej HOSE 0 PIPE E]MUSHROOM CAP AT(>3 _.__`FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations.0ndail applicable Calif o��lalaws. <br /> Signed <br /> Print Name <br /> Date-_UE LA FoE�JJ77F ­ (, I?_C, 112 <br /> DEPARTMENT USE ONLY 4�A L-,�,C 5r-c- <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 2 y C. /( r" <br /> WORK PLAN DATED. 110 <br /> APPLICATION ACCEPTED BY 4 DATE ISSUED AREA IG <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMEN I'S/CONDII IONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> pl..i CODES FEE INFO AMT REMITTED CHECK# REC\rD BY DATE$125x INVOIC17-1, <br /> "N, Go '( 0-,,L,v r4k (e-Z4-V3 SR# 1/6-61 <br /> RO# <br /> (3500) <br /> PR# <br /> (2900) <br /> C-57 WC WAIVER_ tV V1C-57 LETT _ER OF AUTHORIZATION TO SIGN PERMIT L,-__ENCROACHMENT DOC A-'4 <br /> EHI -01 55109/12 - WELL PERMIT APP <br />