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oh44'fA:• f <br /> SAN JOAQUIN COUNTY <br /> r. . .'� <br /> EN • WMITIGPACONMENTALHEALTH DEPARTNf�NT1868 Hazelton Avenue, Stockton, CA 95205-6232Te%phone: (209) 468-3147 Fax: (209) 468-3433 Web:wWW�s• ON <br /> WELL & BORING PERMIT APPLICATION n T <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIAT <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE to ISSUED '% 18 2014 <br /> JoaquinltlCounty Development Title, <br /> ��Chapter -1115.3,and ethetStandards of the construct San Joaaquin C unll the work ty Environmental <br /> on ental Heialth Cape EIRM <br /> Site Location �2t S./�maz,CAA. 5T- t <br /> Property Cross Street _ l(fp{yc City/State SfOpKnv IT/SEflVICES <br /> Owner I/1"26IL 11 ClfIl far./ �iNrarallo zip 95ao6 APN I y=l- 2 <br /> Address ;2//�f he A <br /> C-57 Contractor tll1, rTf�P City/State�7IE CKt'DN <br /> Consultant/Sub Cntr Address . BOO Do-/I ,5'ee_ Zip S'24 Phone <br /> City/StatW`.SaciascMlL Q //O <br /> Z�C- Address 2Z3S�C/1GtrPVW _J Phone &—l(0g <br /> Billable Party StM� --�:± City/State�fq/l4 Lic PG" 6y phone <br /> Address City/State ��� <br /> GIS Coordinates:X Zip <br /> Z _/� LAr., .Pi7,q N5&p Phone <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELVBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> 0 SOIL BORING IDs <br /> SWELL IDs — <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE <br /> �MONITORING CONSTRUCTION SPECIFICATIONS <br /> �OLLOW STEM DIA.OF BOREHOLESS=r <br /> _0 EXTRACTION Vapor/Water 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Z rr <br /> _O SOIL VAPOR PROBE 0 HAMMER/DRIVEN CASING THICKNESS SCk �{ <br /> ❑MUD ROTARY DEPTH OF GROUT SEAL Z 1'/ REMIE CASING: E STEEL AUG EI S OTHER <br /> _O SOIL BORING ❑PUSH POINT GP/CP TREMIE TYPE TO BE USED: ❑AUGERS <br /> _0 INJECTION('e N Sp,r, ( n GROUT SEAL PUMPED:�y yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 0 HOSE PIPE <br /> — ?OOTHER: GER GROUT SPECIFICATIONS �( y d/ngQN70drr0t <br /> _0 OTHER:_— ❑OTHER: POraTUF,�, <br /> APPROX.BORING DEPTH/ tll� Qy W�61/T <br /> COMMENTS: CONDUCTOR CASING a Np Yes:Casing Dia- BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> Casing Depth:_ Bonng Dia <br /> DESPERFORMED: : <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> TRUCTION WORK TO BE <br /> #OF WELL(SJ TO BE DESTROYED DESTRUCTION METHOD. CHECK ALL THAT APPL <br /> WELL IDs: ❑OVER-BORE DIAMETER OF <br /> GROUT SPECIFICATIONS ❑ PRESSURE GROUT TO DEPTH OF INCHES TO DEPTH OF <br /> TREMIE TYPE TO BE USED: AUGERS HOSE PIPE ❑EXPLOSIVES FROM CE <br /> FT <br /> COMMENTS F1'BELOW SURFACE <br /> ❑MUSHROOM CAP q7(>3 FTI FT BELOW SURFACE <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION A TNIOPP MFENTS T BELOW SURFACE <br /> I hereby certify th a re ar dl ' <br /> Regulations,and I a p p application and that the Work will be done in accordance with San Joaquin Coun <br /> 'app <br /> alifornia law . <br /> Signed !�-�, ty Ordinances, Rules and <br /> Print Name Title/Company 2 <br /> 1 RV3 FAL° 6/S/ j �f <br /> pp DEPARTMENT USE ONLY Dated//L// c� <br /> SITE fv1PL IN UNIT IV FILE-SITE ADDRESS VJ S <br /> WORK PLAN DATED Q /�!2 err r-I <br /> APPLICATION ACCEPTED BY /y <br /> GROUT INSPECTION BY ..l Aw�U� <br /> DATE ISSUED �]–Z='Y AREA /6 Y <br /> DESTRUCTION INSPECTION BY FINAL INSPECTION BY <br /> COMMENTS/CONDITIONS: DATE DATE <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMT REMITTED CHECK# FAC# <br /> RECV'D BY DATE SERVICE RO# <br /> V / <br /> $125x if 1736 OZREQUEST PR# INVOICE <br /> SR# 7v� <br /> RO# <br /> 3500 <br /> WC PR# <br /> EHD zs-ot 5/09/12 WAIVER PL - C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br /> ___900 <br /> ENCROACHMENT DOC /Ut <br /> WELL PERMIT APP <br />