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SAN JOAQUIN COUNTY <br /> -crr �Z ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> V.y` SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> Telephone: (209)468-3454 Fax: (209) 468-3433 Web:www.sigov.ora/ehd <br /> WELL & BORING PERMIT APPLICATION RECEIVED <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIA <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED jA'J 9 <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 comp iaMc 2 n <br /> Jo i evelo m n Title,Chapter 9-1115.3,and the Standards of th San Joa u' County Environmental Health Department. <br /> ,S�� <br /> EAR /ylLx 8r✓off %R9Zi9S370NVI <br /> NMENTA <br /> LSite Location S!/E Cross Street City p <br /> Propertyld76 <br /> Owner 71609 Address CityS114✓ViIpAr�oSPhon <br /> �-Q <br /> C-57 Contractor /9b4 ,Ole/L'0',A/(ess q SS /6.9PhC <br /> 3-�s.0 vU <br /> Lo /f �►O LichfPhon <br /> Consultant/ Address������ lXeR� S4A".D/ 6 S2 <br /> Billable Party S _s%OAI�. Address <br /> i6 —IrR/ /1-ljE <br /> GIS Coordinates:X <br /> e <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> LZWELL IDs <br /> OTHER IDs ' <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS t l <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE /d ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIAD <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS Sell ed TYPE OF CASING: ❑STEEL VPVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 4 TREMIE TYPE TO BE USED: rIkAUGERS [IHOSE ❑PIPE <br /> _❑SOIL BORING [IPUSH POINT(GP/CPT) GROUT SEAL PUMPED:39Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.AirSoarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH BOLTED TRAFFIC BOX OR STOVE PIPE <br /> _ CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: jAEu Z-yZoo I-Vi/ /✓✓�'� L �✓�ic�GL�L' G <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepare is application and that the work will be done in accordance with San Joaquin Coun Or ances,Rules and <br /> Regulations,and all applicab ifornia Laws. ,SAH/O'Je L/t//t/ <br /> Signed ATitle/Company ✓���Ru/N (y�~N�y'P�V--tll� td_ <br /> Print Name 1047 ZWi A94 L Date ice . <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS <br /> WORK PLAN DATED //"///Z— <br /> APPLICATION ACCEPTED BY /t/a f<<'�`� a .� '✓c- DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: - o� s N �J• G �i� u/�''�1"�� <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR/# <br /> Yq7 r $125x SR# ik 11 <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />