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ORIGINIL t <br /> �4utly <br /> SAN JOAQUIN COUNTY - �, <br /> - y ENVIRONMENTAL HEALTH DEPARTMENT ` <br /> ... ,� L � <br /> • 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE �tIGAT[ON <br /> c`' • a-- :P Telephone: (209)468-3147 Fax:(209) 468-3433 Web:wwws' ov.o leh U,IT IV I <br /> INN 4u <br /> WELL & BORING PERMIT APPLICATION LTH <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIALTiQPti�1fA1-H <br /> �Ysrr�+ S <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Ery PEF�;VI1iIS�R�IIGE <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development T•ltle,Chapter 9-1115,3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 3U 2 9"l sIi ii;i Cross Street City/StateZip-ZipAPN 1253 206 <br /> Prope <br /> Owner Address 031 " ®Ir city/state Zipa 2:11 Phone <br /> C-57 Contractor � ,ti kPVAddress IKI10 (cec _villi City/State Lic .f (0 G Phone 3e -2-610 <br /> ConsultantlSubCntr Address3ol-I �.f.s,t>Qd.ISI�j}[IAD City/State�c,M4lrrrulAl►�L�icGsyY94� Phone 1 'Dy00 <br /> Billable Party Address City/State Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED- <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ©SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> `❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:[ Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> �❑INJECTION a e.Air Soerne.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER:. APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Die: 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 BE DESTR YED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: - ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SIDECIAF CA ONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑PIPE ❑MUSHROOM CAP AT L3 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 CalifomI laws. <br /> Signed Title/Company d ' <br /> Print Name K, -Date 3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 3 2 Z &I- /�A1 d n0401sY. - W'CIyl <br /> WORK PLAN DATED -f3 a f+ 2'e-0—, <br /> APPLICATION ACCEPTED.BY Gt� bAT REA� <br /> GROUT INSPECTION BY FINAL INSIDE TI N BY ATE 6 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECKS RECV D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> r��r2 5o Z $125 x 73�\ &C w- U' SR# <br /> 35x3 3�s 376pa <br /> 2900 <br /> C-57WC I/ WAIVER A/I+- - C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC HG <br /> EHD 29 01 5!09112 WELL PERMIT APP <br />