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fLl SAN JOAQUIN COUNTY ' <br /> ENVIRONMENTAL HEALTH DEPARTMmNiLE Ney <br /> SIE MITIGATION <br /> LGA <br /> x� <br /> .1 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> ..;¢ Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.s*qov.org/ehd O <br /> ��Foae' <br /> WELL & BORING PERMIT APPLICATION WIC <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION I/ /S 1W—C <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �iJY/ <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appitcaticn is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department, <br /> L <br /> Site Location � �` I.1JE 5T _ Cross Street N, _' 1,; - <br /> City 7�� jf' Zip �l APN <br /> Property, r. <br /> r/ <br /> Address j ; Ecity r7 whon <br /> e <br /> —0Owner -: <br /> -- _ 7 Phone` LicG 57 Contractor dress a .. <br /> Consultant/SubGntr_�.�)_''.'.._"_...�._........_..........._r_.._.Lt�:l—�--_ Address I ity Lc �g7�PPhone <br /> Billable Party Address City Zip - <br /> e <br /> ' <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING (CPT.GEOPROBE.HYDROPUNCH, HAND-AUGER,OTHER) <br /> ❑ SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑ OTHER IDs <br /> TYPE&#OF WELLJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MON}TORING ❑ HOLLOW STEM DIA-OF BOREHOLE ❑MULTIPLE CASINGS❑ MULTI-LEVEL WELL uASING DIA. l� <br /> ❑EXTRACTION Vapor/Water ❑ HAMMER0RIVEN CASING THICKNESS TYPE OF CASING ❑ STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OL GROUT SEAL TREMIE TYPE TO BE USED ❑AUGERS ❑ 110SE ❑ PIP' <br /> ❑SOIL BORING ❑ PUSH POINT(GP!CPT) GROUT SEAL PUMPED [:]'y F-,s ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTIONS 4i 5y rhe j❑ HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER <br /> ❑OTHER APPROX BORING DEPTH ❑ BOLTED TRAFFIC BOX OR ❑STOVE PIP <br /> CONDI;CTOR CASING[]No❑Yes Casino Dia, Casiriq Depth. B ging Dia <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:((->ECK ALL THAT APPLY) <br /> #OF WELL(S)-a BE DESTROYED OVER-BOLL DIAMETER OF 1S INGHES To DEPTH OF 7 7 FT <br /> WELL IDs: M LAJ 9 PRESSURE GROUT TO DEPTH OF FT aELOa% SHRFACa <br /> GROUT SPECIFICATIONS s r O O . >Z! 7 ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED ❑ AU ERS ❑ HOSE PIPE ❑ MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances. Rules and <br /> Regulations and all applicable California laws. <br /> Signed �� �!� '- TitlelCompwiy L- _ <br /> r <br /> Print Narne Date <br /> DEPARTMENT USE ONLY �'�( <br /> SITE MAP IN UNI i `- <br /> €V FILL -SITE ADDRESS �l� �� ��t-i <br /> WgRK PLAN DATED7- 13 f <br /> -- _ <br /> APPLICATION ACCEPTED BY - NAL-1 <br /> D L7 � .` �__ AREA <br /> GROUT iNSPE�TiON I Y _ FINAL IN SPECTIC)N i3 '. - -- ....- <br /> DATE tt <br /> ........................................ ............................... <br /> DESTRUCTION INSPECT ION 13Y -Jvkq 0 A'V-V M. DATE <br /> COMMENTSICONDITIONS: <br /> ACCCtUN TING C]NL!'. AID FAC r <br /> PE CODES SERVICE ; RO N FEE INFO AMT REMITTED CHECK# RECV'D BY DATE INVOICE <br /> �........ . - ... ....._.� — .._L---- REQUEST � AR# <br /> I <br /> �" s. f — <br /> D° 37 5 on - <br /> 3 __....... _ ..._._... <br /> i <br /> C-57 WC WAIVER. C-57 LETTER OF AUTHORIZATION TO SIA k T�i7- � ENC:ROACHMENl DOC <br /> FH029-01 0:/28,'1u WELLP RP A P <br />