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o�q''':'?'• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE�VIITIGATION <br /> :. <br /> Telephone: (209)468-3147 Fax: (209) 468-3433 Web:WwW.Siaov.orcg/ehd UNIT IV <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND RE EDIATIORM'TAk-�`" � <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r o, 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 Tale,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 32-12-Nor• Cji��.Cross Street �+�e. City/State, {evVC�Zipgo� APN I 2�6/_ <br /> Property. <br /> Owner f J Address City/State�4m zip 2s III Phone <br /> C-57 Contractor ��pp 10L&fAddress1q,10citylState L s lri Phone 36 -2-6/0Consultant/Sub Cntr-,% cu Rha Address I 00 City/State 6(.A*�Lic GsyY q -Phone q+' 961 000 <br /> Billable Party Address City/State Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs +, <br /> ❑WELL IDs <br /> ❑OTHER iDs { <br /> TYPE&#OF WEWBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �❑MONITORING ❑HOLLOW STEM I DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DEA: <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 /> _0 INJECTION(i a O on ❑HAND AUGER GROUT SPECIFICATIONS <br /> ^❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> 6 Z CONDUCTOR CASING❑'No❑Yes:Casing Dia: Casing Depth: Boring DW <br /> COMMENTS: -} <br /> NOTEV OFFSITE/WELLS.&IiORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WOR PEU&gMM DESTRUCTION METHOD: CHECK ALL THAT APPLY <br /> Ste#OF WFLk(Sr r E Y OVER-BORE DIAMETER OF INCHES TO DEPTH OF-F T <br /> WELL I W' PRESSURE GROUT rp DePTH of FT 9ELOW SURFACE <br /> GROUT - S t - Q EXPLOSIVES FROM TO FT BELOW SURFACE <br /> �-� MUSHROOM CAP AT �3 F FT BELOW SURFACE <br /> TREMIE TYPE TO 13E US :❑AUG OSE E ^I -5 © ,L T1 <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules an <br /> Regulations,and all applicable Callfoml laws. 2 <br /> Signed <br /> Title/Company d� ' > 7 <br /> Print Name �'� f Z`r'1 Date 3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT 1V FILE-SITE ADDRESS 3 - v <br /> WORK PLAN DATED �t't' v/Z <br /> 101- <br /> APPLICATION ACCEPTED BY -i•`�D "'� DATE U ��G-�3 AREA <br /> GROUT INSPECTION BTIO B DATE <br /> Y FINAL INSPE �2a <br /> DESTRUCTION INSPECTION BY a 4,- DATE <br /> COMMENTSICONDITIONS: d s <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# <br /> 3 (�aM $-1512 SR#TO $125x 75d� RO# 0171 <br /> 35a3 3?5 375 sSOD) <br /> PR# <br /> y 2900 <br /> C-57 WC V - WAIVER A/fq- - C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT- ` ENCROACHMENT DOC NRl <br /> EHD 29-01 1013112 - + WELL PERMIT APP <br />