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SAN 'JOAQUIN COUNTY ip <br /> LOP <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION <br /> UNIT IV <br /> 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209) 468.3464 Fax:(209)468-3433 Web:www siaov omlehd <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 s.permit to construct and/or install the work described. This application Is made in compliance with San <br /> Joaquin County Development Tile,Chapter 9.5115.3,.and the Standards of the San Joaquin County Environmental Health Department. <br /> 10IP �� RLIL Cross Street�!C City f;'M (Amp ZIp�,— APN (Ct`�i�� <br /> Site Location}SQes.1- �.�_ O DOJ leis ti ��pp��...���� <br /> Property 6 e hfA Zip(.0II f—Phone �� 4-Bf32L <br /> Owner r)Ae„n P LG. 2041Ona Address(yG g SToP lei_ City ,, rn <br /> C-67 Contractor 2� Address q5o Naw _�t�� JJ City FI�nLPnr.2_—LIc4QkS 165%X76_-Phone 425-313 -560? <br /> ConsultantlSub Cnndt''rG/1L 1�6V Addreas y 4 1 A City F •-••r tl Licg 3 phone X10-42o-O�00 <br /> Billable Party 114 � Address cape IW!N 5�� fW1. A City "�'�`-'—ZIP `t d5 Phons51rr NZtO"d'7C0 III <br /> GIS Coordinates:X - Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> -p'NEW WELUBORING(CPT,GEEOPROBE,.HYDROPUNCH,HAND•AUGER,DTHER)_.... -_ . ... . - - <br /> .E SOIL BORING IOs - <br /> I]WELL IDs <br /> t]OTHER IDS. <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONS reiICT10N SPECIFICATIONS <br /> �MONITORING D HOLLOW STEM DIA.OF BOREHOLE _[3 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> _❑EXTRACTION:Veporr Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC O OTHER_- <br /> ,—pI]SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIETYPE TO BE USED: [I AUGERS HOSE Ll PIPE <br /> tyMISO1L BORING6XPUSH POINT(OPI CPT) GROUT SEAL PUMPED:❑Yea Ll No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ❑INJECTION II.Au 8oeras Qzmel❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: [I OTHER: APPROX.BORING DEPTH `• <br /> 2a ❑BOLTED TRAFFIC BOX OR 11 STOVE PIPE <br /> CONDUCTOR CASING[INo❑Yea:Casing DIS:__Casing Depth:__ Baring Die:__ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: j1P'�TRUc71ON METHOD-rcxecx AU THAT APPLYI <br /> _#OF WELL(S)TO BE DESTROYED <br /> C]OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> WELLIDs: EXPLOSIVES FROM TO FT BELOW SURFACE <br /> GROUT SPECIFICATIONS FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERS - HOSE EI PIPE ❑MUSHROOM CAP AT Q3 FT) <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have DrOpAred this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulallons,and p Ilfornl S. <br /> Signed <br /> Title/Company ' <br /> Print Name U Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-,SITE ADDRESS O - <br /> WORK PLAN DATED I (1 AREA <br /> APPLICATION ACCEPTED 8 _ DATE II? ED <br /> GROUT INSPECTION BY <br /> FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY <br /> DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# <br /> e2`14 $122x lzz. G 3�81I sit# (A20��' <br /> RO# <br /> 3690 <br /> / PR#oS1u' <br /> X3(0(0 //p7 .1!61 32900 <br /> C-57 'WC WAIVER C-57 LETTER OF,AUTHORIZATION TO SIGN PERMIT ENCROACHMENDOC— <br /> WELL <br /> O FERMI7APP <br /> EHD 20.01 07128MO <br />