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0 <br />¢Qut" SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />•':'• 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.s0Qov.ora/ehd <br />LOP <br />SITE MITIGATION <br />UNIT IV <br />WELL & BORING PERMIT APPLICATION <br />FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <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 San <br />Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. <br />Site Location /�71� ~�osreet ® City/State G�1 «Zip ���0 APN o6 JPrope <br />Owner�11/��%��/Qt//i✓ �G>!/✓i7i %aWD s t �'LipA Phoneme .� <br />Address A L lf�P=-E�Tc�✓ Cit /State Sf�kiv 9 �i�/ Qo1F 'K6d - V 6 6 <br />10 v AI L. ¢gS/6&Phone 7 -4 .��� ' s �CA <br />C-57 Contractor IiQIT/C� l� Address �� e a City/State C Lie <br />E B £ ec> v w ,1 <br />Consultant/SubCntr _ Adte s City/Stat �.�o LicC /7�% Phone <br />Billable Party � t�6/ & WIAI «Address Ay/Stat s% Zip <br />GIS Coordinates: X c3 8 �JPI' Y /.�G � <br />N WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) <br />❑ SOIL BORING IDs <br />WELL IDs -, <br />OTHER IDs <br />TYPE S # OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONSC,�� E 'W&X & it <br />-10 MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE (O 10*00MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br />_❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS __TYPE OF CASING: ❑ STEEL APVC ❑ OTHER <br />_❑ SOIL VAPOR PROBE MUD ROTARY DEPTH OF GROUT SEAL 3S TREMIE TYPE TO BE USED: XAUGERS WHOSE ❑ PIPE <br />_❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED:}$Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />_❑ INJECTION (i.e.AirSoarae.Ozone) ❑ HAND AUGER �,/GROUTSPECIFICATIONS 6; <br />_❑ OTHER: '9 OTHER: 411f If0'14'AYAPPROX. BORING DEPTH 75" 1--7- ❑ BOLTED TRAFFIC BOX OR 19STOVE PIPE <br />COMMENTS: Pea GyZA�ic''n 1i✓67S7 rwe- R C� ❑�� Ye���� .Casing Depth: Boring Dia: <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 (>3 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 prepared thipdolication and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and all applicable Cal' is I <br />Signed Title/Company rlo�v �DQu�� «rNri Pwa rfvz/� <br />tbow X'7 . <br />Print Name ���%%C�.eiQC/ZL Date � 30/ 1�/3 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS_ <br />WORK PLAN DATED`' 7, 20 <br />APPLICATION ACCEPTED BY /l/il- L?!kA ,J ee 313-0 /1/1 <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTIONBY <br />COMMENTS/CONDITIONS: <br />—n'14 DATE ISSUED 5 A /3 AREA <br />FINAL INSPECTION BY DATE <br />DATE <br />9Wx11b li!L / O lt/ �»R <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE <br />SERVICE <br />RO # <br />INVOICE <br />REQUEST <br />PR <br />4�C 7i <br />$125x <br />SS ! <br />(/�> <br />yll �j <br />/# <br />SR# % <br />SE Z) 01 D! (o <br />RO # <br />3500 <br />PR # <br />2900 <br />C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />EHD 29-01 5/09/12 WELL PERMIT APP <br />