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CONSTRUCTION WORK TO BE PERFORMEDt <br />ANEW WELL/BORING (C T. C.EOPROEle HYLIRAPLICt4 hAN0 AUGFA OTHER! <br />D SOIL EORING &ELL !Ds <br />OTHER IDs <br /> nry <br />Print Nanny KrILL_Ativ 116.92r- <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209)468-3454 Fax: (209) 468-3433 Web: www.sIgov.orgiehtl <br />WELL & BORING PERMIT APPLICATION <br />FOR WELLS AND ORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDATION <br />NON•REFUNDABtE PERMIT EXPIRES 1 YEAR FROM DATE ISSU,ED <br />Apt:sleeken .s hereby made to San Joaquin County lor a permit tu construel author insin'i the work down text This applcation is mode in compltance with Son <br />Jon nr.tin gow4Elevettrunent Up. Chapter 9-1115.3, and the Standards al Um San Joaquin County Environmentoi Health Depart nenl. <br />eGIStwr <br />Situ Location 519 5#94frrti 44 tvect.vh C,ct8St.tet neA.00,444r.v.,-1 44- <rowe-- zip 145 /74 APN Properq _ <br />Owner 1/4•Vrri St tedde""" Address City Zip, Phone <br />C-57 Contractor .,T,.5",rt.,...prraVais Address ZZC)J.J City tA,)atstki,posok. Loc,201,A3Whorn atils—rkrt-4 <br />ConsullantiSub Cato' Andress Crty Lit Phnne <br />Billable Party /41;_feititrA/4C Addrets C tr1-2-00/ y 54CriAdffe,W719 Zip 90/6 ritone, 1/6 -41:).5"--vio <br />GIS Coordinates' X eiolqbea e y '12-47 // Vo ;1 /4-1 caw) .05 <br />TYPE 34 OF WELL/BORING <br />tomrowric; <br />I RACTION VJ jo,) Wand <br />SOIL VAPOR PRCBE <br />o SOIL BORING <br />IINJEC110E1 op-,01 <br />_0 (11HER <br />INSTALLATION TYPg <br />1:iittrOLLOW 0E41 <br />tog.i4iSittrmiyit. <br />E3 MUD ROTARY <br />PuSH O1G,t41j <br />0 IlkNO ALIGER <br />oTtieFt <br />CONSTRUCTION SPECIFICATIONS <br />tulA 01 nottEhoLC 6 0 ItlijLTIPLE CAStnctaS0 MU LT ..LEVEI. WELL CescritS <br />c140 TticKNEss 2 ' TYPE Cf (,'.4,9d10- 0 STEEL jaPVC 0 OTHER <br />CIE PHI or GROUT SCA,- 3 1lWitC TYP C.' 10 DE LiSE0 0 Au GERs (Tkloss. 0 PIPE <br />cR0UT Sr-AL pt./1.110CD Ciis gegn (MAXIMUM FREE. EAU_ 0:P114 1S 30 FT). I <br />cRoUr SFECirt-C.ATIONS .r...C.Gilir....16"/"PiLM ervie#01- APP110X (5;44:1"; CEPit tir, BOLTED TRAFFirt rt,01( OR 0 STOVE PIPE <br />Cf+SING cyLori Ye 9* Criu,an Da: . Cusgq DMRUI e4M119 Dia <br />5 .t,,et 5 T. COMMENTS: Z4X-t <br /> <br />GROUT SPECIFICATIONS <br /> 0 PRESSURE GROUT TO DEPT!' Or r-r nm. c*A 5 unrAcr <br />pfSTRUoTioN pio-TH9D1 (crec.; ALL Trio- ADL--,Lyi <br />DOvER•RORE DIAMETER or INCI•IES TO Den-, Uf 17 <br />0 EXPLOSIVES IR,Dr.t 'Cl rT PEI .W1 SVII,ACE <br />0 MUSHROOM CAP AT (,?. r I i rr 13EI OW P.iP.FACE <br />'NO <br />5 WORKING D YS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />I hereby certify thrd o moans is application and Ihnt the work will he ddrio Irt accordance wan San Joaquin County Ordinances, Rules and <br />Regulations, a bile fø la laws. <br />6-...r / <br />Dale Yiii /SY" <br />APPLICATICN ACCEPTED BY <br /> <br />DATE ISSUED b AREA <br /> <br />(,Rout INSPECTION BY FINAL INSPECTION EP/ <br />DESTRUCTION INSPECTION BY DATE <br /> <br />DATE <br /> <br />COMMENTS/CONDITIONS: <br /> <br />ACCOUNTING ONLY: AID 0 FAC s <br />PE CODES FEE INFO AMT REMII I 0 CHECK 0 KCVO BY DATE SERVICE <br />REQUEST <br />RO fi <br />PR 0 INVOICE <br />Ago( lox 2... P. Y t(7- Vie-A- 6 2;1u <br />_ <br />SRO 62.154 I <br />(3500) <br />_ <br />PR N <br />psoo) <br />4 <br />LOP <br />SITE MITIGATION <br />UNIT IV <br />NOTE; OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />DESTRUCTION WORK TO BE PERFORMED: <br />or writ IP TO 5P 1:107,11(t)Yr <br />vr-IL fps. <br />IREMIE TYPE TO BE USED. U AUGERS 0 HOSE 0 PIPE <br />COMMENTS <br />DEPARTMENT USE ONLY <br />SITU MAP IN UM!' IV ALE - SITE ADDRESS 1.1JSZ4-C.4 4 bi1A4[4:21L._ <br />WORK PLAN DATED <br />— C-5/ LE I1EF O AUTHORZATION 10 SIGN PERMIT ENCROACHMENT DOC Elia 2941 0/ 26,10 WELL PERLItr APP