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P0.Y�N SAN JOAQUIN COUNTY <br /> LOP <br /> T.. ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION <br /> • 600 East Main Street, Stockton, CA 95202-3029 UNIT IV _ <br /> • cq..- ,a;P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.orcM1C <br /> /FOR <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIADDO 13 2010 <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 R0NMFrtAiAEeRE"THi <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health DepartKAMI /SERVICES <br /> Site Location "t��t� / ��R Cross Stree '.. w is City Zip `-5 APN <br /> Property'• n `. . <br /> Owner ��-taT `y Address tE ���� �`�M City`yJ Zip SVP j Phone�(,�b <br /> C-57 Contractor Address9.0 • I 144 City-2e4wAQ'P,'jiv Lic �;3iAb Phone <br /> Consultant/SubCntrAddress 1i `n, NFS" City N , 1,�D L)�,, LicN5 b b Phone <br /> Billable Party�,lc,�' y`✓ Address Iv 1�1-4h rz:IV 0 11'4, i'-T' City QA-1,L,) Zip Phone JVD 5�1-00;dL <br /> GIS Coordinates:X 2.1 _' ,'JQr. Y 1s.3 AL aO:r •156 <br /> 719 <br /> CONSTRUCTION WORK T BE PERFORMED: <br /> ❑NEWyWELL/BORING(CPT, l �}HYDROPUNCH,HAND-AUGER,OTHER) <br /> [ SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> —X'MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS k) TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL C r',/ TREMIE TYPE TO BE USED: TAUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING [PUSH POINT(GP/CPT) GROUT SEAL PUMPED.N.'Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.AirSoarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS� <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH /J ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING 4-No❑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 BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑ PRESSURE 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(?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 ave prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulati s,a a plica le California laws. <br /> Signed c Titie/Company ~ i >v <br /> Print Name W �o Date )^A <-3 16 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 200S <br /> WORK PLAN DATED C OR-k/Q L )OL). Z <br /> APPLICATION ACCEPTED <br /> 1BY� DATE ISSUED � �� /D AREA `7 7 7 <br /> GROUT INSPECTION BY /'� FINAL INSPECTION BY DATE / J <br /> DESTRUCTION INSPECTION BYnn DATE <br /> COMMENTS/CONDITIONS: L V��"J�C ak > <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> ,�� j— I REQUEST PR# <br /> • D � $ 122x � � I�-�`-f l�� _ `^�� (O SR#DO(917/? <br /> 3500 <br /> PR <br /> 29000 <br /> C-57 WC WAIVER _ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 WELL PERMIT APP <br />