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SAN JOAQUIN COUNTY <br /> ck.,U14. <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street,StodaDn,CA 95202-3029 <br /> SITE MI i It3AT10N <br /> Telephone:(209)468.3454 Fax.(208)468-3433 Web:www.slaov.om1shd UNIT N <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> (VON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appticallon Y hKOW nada to San J08QUTA County la a pemdt to ooratruct ands Irstall ua wm deeodbed. TMs application is made M compliance with San <br /> Joaquin Courny Dewboment TIS.Chsp1N"...•" -- rqy Emkonmentsl Heatlh Opperbraft <br /> Mokelumne River Drive&Awani Drive 041-410 <br /> eftL90~Lodi city landfill Croce Sweet �___. Lodi _a( 95240 MN _ <br /> Property City of Lodi Aadr�s 221 west Pine Street _ CityLodi zap 95240 �„ (209)333-6801 <br /> Owwc-s7Commowl a7Dw�{It?DD¢lw 5 r city ro �s _Lic__5 240 <br /> Pmm- 7�� 37y"y3 <br /> consult nvsub Cntr Ninyo and Moore ` 5710 Ruffin Road_ c*Y_ San Diego _w Ptww (858)576-2000 <br /> But"Part Address Cay zip Ptvne _ <br /> GIS Coordinator:X_ <br /> 3$.14875 -121.27025 _SEE ATTACHED SHEETS <br /> NEW WELL/BORIN(3(CPT.GEOPROBE,HYDROPUNCH.WWDAUGER,OTIMR) <br /> SOIL BORT <br /> Vi WELL IDs <br /> ❑OTHER IN <br /> TYPE&tt OF WELLMORIIIO INBTAI.LATION TYPE CONSTRUCTION SPBCIA_w,&jm <br /> MoNITORm 19 HOLLOW STEM OW OF 9OREHoU p/y'. Q• ,',-IDLE CWNGS O M LTH.EVEL WELL CASINO Dik <br /> ` porr EXTRACTION!VeWad. O HAbA4EtIDRIVFN CASING THlt ss V�3TYPE OF CASeKi: O STEEL ('d PVC O OTHER <br /> i0b SOIL VAPOR PROM O MW ROTARY DEPTH OF GROUT BEAU TREMIE TYPE TO BE USED: O AUGERS O HOw O mPE <br /> ,O SOL BORING ❑PUSH POINT(CW CPT) GROUT VAL PUMPED:O Yes O No(MA)OMUM rREE FALL DEPTH 6 30 FT) <br /> _O INJECTION a—*_4k eemrl IN HAND AUGER GROUT SPECIFICATIONS— <br /> _O OTwA OTHtBt f` 11 y� APPRox BORING DEPTH_Bentonite Q BMTED TRAFFIC BOX OR O STOVE 31PE <br /> SEE ATTACHED SHEETS CONDUCTOR c"M O No O Yes:CaoV Ott Caft Dept 99"DU <br /> COMMEM: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUI BE WORMED: RgSTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> M OF WELL(S)TO BE DESTROYED L3 OVER-BORE DIAMETER OF WCFIES TO DEPTH OF___FT <br /> WELL IDs: ❑PRESSURE GROUT To DEPTH OF FT eaow WWACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOWsuRFAcE <br /> TREWE TYPE TO BE USED AUGERS HOSE PIPE ❑MUSHROOM CAP AT L?3 FT) Fr aELOw EURIACE <br /> comme B <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I herby cer""1 have propand this application and that the work will be done in accordance with Sen Joaquin County Ordinances,Rules and <br /> ReptaaHoaa }nd all appilabh Ca1lFortNa l.awe. <br /> fined � � Ue/CompenY SSD -- p ! �G�� J <br /> Print Name A/ � Dab 7 O <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT N FILE SITE ADDRESS <br /> WORK PLAN DATED �d <br /> APPLICATION ACCEPTED BY /I/' �1!-e-e Ai.tA.--c DATE ISSUED _V-&/2-/z AREA _ <br /> GROUT INSPECTION BY FINAL INSPECTION BY Z-DATE 3 / �L <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTWCONDITIONS: - X-101—-,7-e '4- eo-"�"'c- <br /> ACCOUNTING ONLY: AID i FAC# RVICE <br /> PE CODES FEE INFO AMT REMITTED CHECK• REM)BY DATE S auraeT R: <br /> ROINVOICE <br /> REtWESP <br /> LJ�I7r 125x lr/a.?rec� w �876ySY! <br /> RO N <br /> PRO <br /> Cr57 WC __WAIVER _ C57 LETTER OF AUTH il-A ION TO SIG,1,PERMI t —FNCROACHMENT DOC <br /> 3/1 Y//2 -A6 -I' ) <br /> L F G t/ 7 Rcp <br /> 31 Is-//Z - As <br />