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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> ` SITE MITIGATION <br /> • 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> °4</FOR�•P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.siaov.org/eh1M <br /> WELL & BORING PERMIT APPLICATION nECEIVED <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATI TCT 3 1 2011 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is �' <br /> Joaquin County Development Title,Chapter 9-1115.3,andthe Standards of <br /> the San Joaquin Co my Env�iron`mental Health <br /> �Departlm" <br /> Site Location "� )V'Cross Street t � �' L `—���5 � City��W Zi J��>r1 APNM�r�� <br /> Owner `�+it C�r�P Address ( �'� JT City�1L(i0�1,�c�i� Zip tS(61 Phone <br /> C-57 Contractor L>✓�� �JCv Address ity `I A0P- Li Phone �� ] <br /> ConsultanUSubCnt — Address I I City C Lic • Phonems 1-0, � <br /> Billable Party� kA f a_ 1) Address City ZIP Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED-: <br /> ❑ NEW WELL/BORING(CPTr(i PR08E,HAD�p PU CH,I'I AU ER,OTHER) <br /> �I SOIL BORING IDs J �L' l9 <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE y_ ❑MULTIPLE CASINGS C-] cf))MULTI-LEVEL WELL CASING DIA: . <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS �, TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL L,�_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(i.e.Air Scarce Ozone)❑HAND AUGER GROUT SPECIFICATIONS / <br /> _❑OTHER: ❑OTHER: �-1. <br /> �)) <br /> APPROX.BORING DEPTH 0 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING[INo F]Yes Casing Dia: Casing Depth. Boring Dia <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 WELLS)TO SE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDS: [IPRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑ 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 /> Regulat' n ,a alIj Iicjbk Califo is laws. 1 <br /> Signed .•JJ Title/Company E)Vv IRou <br /> Print Name t'-' <br /> k) Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SIT ADDRESS Z c V 4C j <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE ISSUED �I L zo t I AREA 9 g <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: MV101,61 f7 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST , PR# <br /> d lbs s122X_ r 2� 09L2 SQR63661 <br /> RO# <br /> 3500 <br /> P <br /> 900 S3 588 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 <br /> WELL PERMIT APP <br />