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c - 7 <br /> 0 4 i►�. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> u�c T I A ,N <br /> ' -� 1868 East Hazelton Avenue, Stockton, CA 95205 6232 _ }3 <br /> Telephone:(209)468-3.454 Fax:(209)468-3433 Web:wwwsictov,orgleh F <br /> WELL & BORING (PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS.AND REMEDIATIQN <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED ENVIIIUNMF_N•fAL 11FACI-1.9 <br /> Application is hereby made to San Joaquin County for a permit io construct and/or Install the work described. This application is madifllx6Mfktlb'll�FAXON-"an <br /> Joaquin County Development Title,Chapter 9-9115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 25 Sr Ctrl' r W Crass Street , City Zip19 Z APN 0'0 <br /> 8Q-55 <br /> Property r1 G^�O Zi 9s <br /> Owner A- el Address Y o Z Cily / p�Phone D Z3 <br /> C-57 Contractor t l Address city...' rinm" -Lic. q?359 Phone x!'9357 <br /> Address [��Id dl'ta lv• r�!• City-w4vb.[704,5 1Phone to$i;3 $Dl0 <br /> rron <br /> !t gee ZI 0 Z Phone o <br /> Billable Party' <br /> Address"aron Y P <br /> - <br /> tlHR. vtG - <br /> GI8 coordinates'.x �^ Y [Z[.ZL�lp9�i `�a 'T d� lutiy er b �c�e+- •i u c. <br /> f C 2 <br /> CONSTRUCTION W013K TO BE PERFORMED <br /> NEW WELLISORING(CPT,GEOPROBE,HYDROPUNCH_,HAND-AUGER,OTHER) <br /> ❑SOIL BORING!Ds <br /> fl'WELLIDs <br /> ,OTHER IDs <br /> TYPE&#OF WELIJ80RG f STA" CO S• UCT • CIFICATIO <br /> d (NGS MULTI-LEVEL WELL CASING DIA: <br /> EHOLE MULTIPLE CAS ❑ <br /> 1 �yMONITORING HOLLOW STEM DIA.OF BOR � ❑ <br /> I EEL PVC OTHER <br /> CAS NG: ST <br /> . TYPE OF ❑ ❑ <br /> •,-,_Q EXTRACTION:Vapor!Water ❑HAMMERIDRIVEN CASING THICKNESS �� � I <br /> 1 "SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL LrT —TREMIE TYPE TO BE USED: ❑AUGERS HOSE (3 PIPE <br /> '+ 1 OIL BORING VAFD16, ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:jx,Yes ❑No(MAXIMUM FREE FALL DEPTH_ _I$3o FT) <br /> _❑INJECTION ae Jur 5oerge.Qzgmt❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROK BORING DEPTH ' tab J�CBOLTED TRAFFIC BOX_ OR ❑STOVE PIPE <br /> �fJ Ali-If <br /> ` <br /> CONDUCTOR CASING P(No❑Yes;Cesing ! Casing Depth: Boring Dia: <br /> COMMENTS: 1� Al` '0) .+e air • Z ' <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE(ZGESS� EEMENTS ORE CROACHMENT PERMITS -- <br /> D STRUCTION WORK TO BE PERFORMED: DESTFLUCTION METHOD., CHECK ALL THAT APPL <br /> #OF WELL S)TO BE DESTROYED OVER-BORE DIAMETER O •F INC_HE_S TO DEPTH OFjL�FT <br /> DS; <br /> WELL Ir ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Ce [I EES XPLOSIVFROM TO FT BELOW SURFACE <br /> TREMIE TYPE T.-BE USED:QA ERS H E PIPE USHROOM CAP AT L>3 FTI- FT BELOW SURFACE <br /> COMMENTS 0 �►�` <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS ' <br /> I hereby certify that I hav repared this application and that the work will be done In accordance with San Joaquln County'Ordinancgs,Rules and <br /> Regulations,and Its 1 I Cailfornla Laws. D n <br /> Signed / `•�. Title/Company err <br /> Print Name -e T DaeDEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE S TE ADDRE S top S"""am •(3 / <br /> WORK PLAN DATED I <br /> APPLICATION ACCEPTED By _ _ DI'TP ISSi1!~D AREA Q,_2_ <br /> GROUT INSPECTION FINAL INSPECTION } _ DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING.ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> :55VI $125#2- 6 3$I? o SR#a00so 67 IND I Va62- <br /> 10 <br /> RO# <br /> g L 3500 r�S 4z I <br /> 75d� ZSR a 2 00 N/A <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />