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op4H':.N. • SAN JOAQUIN COU"" • n n I rm 14, <br /> ENVIRONMENTAL HEALTH C <br /> ON <br /> 1868 Hazelton Avenue, Stockton, <br /> �•..,. -:•;� Telephone: (209) 468-3147 Fax: (209) 468-34 <br /> risbn <br /> WELL & BORING PERMIT , 707 Sa7fp <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YE /` 0 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the i San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaqu' — <br /> SiteLocationWAZ 5-)141aloi't-"'crossStreet L- Wo1e-ThL <br /> Property <br /> (�RoPddrrtss IG_�L+resTaucSr:#� }- <br /> Owner H11eiAc4j .Ud• rm1t Address <br /> C-57 Contractor &5e4 e Viilher - Address 000 Djjlrfh STreef �l169 <br /> Consultant/Sub Cntr 6my , /NG- Address'7,3y-A7&eoul2`f Nor 0150 <br /> Billable Party 4�4,146* Address <br /> GIS Coordinates:X Y '�W`6 L4f: 39 <br /> 37 G7 `121 xa 5 Mw- * LA-r. 3-4gk5631°i LING --- - - <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> [],SOIL BORING IDs <br /> WELLIDs MW M A -1- <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 7r <br /> XR(MONITORING 'HOLLOW STEM DIA.OF BOREHOLE 'V <br /> ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS tI�• �lJ TYPE OF CASING: [3 STEEL N' VC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL '7�4 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE PIPE <br /> _�SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED: Yes No MAXIM FREE FALL DEPT S 30 FT) �'bw/D �1K <br /> _[I INJECTION(la Air Searoe ozone)❑HAND AUGER GROUT SPECIFICATIONS t 1 <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING grNo❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <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 SE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDS: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONSElEXPLOSIVES FROM io FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:El AUGERS ElHOSE ❑ PIPE ❑ MUSHROOM CAP AT L>3 Fr) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORK) AYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS . <br /> I hereby certify thI e prep daghis application nd that the work will be done in accordance with San Joaquin County 0 d antes, Rules and <br /> Regulations,al pplicabl alifornia la s. DQ � 'J <br /> Signed <br /> '*z ✓t.G r7 Title/Company 1 FU.� '/ ��w�[S� t7 <br /> Print Nam �'� '�`'���� Date 7/16,/2O1Y <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS e mo 57- <br /> WORK PLAN DATED ff ke ff 19 1 P.r'l<l <br /> APPLICATION ACCEPTED BY J.t1l K4Lp✓\ DATEISSSSCUED 7-21'rl AREA <br /> GROUT INSPECTION BY vG oh FINAL INSPECTION BY /� � DATE l9 J <br /> DESTRUCTION INSPECTION BY DATE <br /> COM M ENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECD BY DATE REQUEST PR# INVOICE <br /> 2p01 $125x 17 G6Z &UV7E2 l0 7y SR# 7()09c <br /> c RO If <br /> (3500) <br /> PR# <br /> (2900) <br /> C-57 ✓ WC WAIVER�v� C-57 LETTER OFAUTHORIZATION TO SIGN PERMIT v ENCROACHMENT DOC A//� <br /> WELL PERMIT APP <br /> EHD 29-01 5109/12 <br />