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SAN aOAQUEN COUNTY <br /> ENVIRONMENTAL. HEALTH DEPARTMENT LOP <br /> 9 ''a'"4 •''• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATI N <br /> •.� F oa�:� Telephone: (209)4G8-3147 Fax:(209)468-3433.Web:www.sictov:org!_ehd', —� N Fi IV <br /> WELL & BORING PERMIT APPLICATION " <br /> f FOR WELLS AND BORINGS USED FOR CONTAMINANT,INVESTIGATIONS AND REMEDIATEONQ <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.made in compliance vAh.San, <br /> Joaquin County Development Tille,Chapter 9-1115.3,and the Standards of the San Joaquin County Enivironmenta�l Health Dep�/rtirient ' t <br /> Site Location 7 -7 g'!jT� 5'�• Cross Street t ` ,t*Tr+t��-��"t R- ,CifylSlale L"r A / <br /> + �/1Zip Lsl 1 APN'�"r���� <br /> propa '`� � I ' „�. /�1. , , <br /> Ower b Address���Yt. sr01�1/� CityistatP""'�•� � uPUL-6 4_Pharie <br /> C-57 Contractor p e�r��5�� _ Address�/S �C�il� City!Stale P47 +nib Lic F-}16 S Phone 9�ZrS <br /> Condultant/Sub Cntr E< ji-OeS -4,%C- Address/.t77 TecA aC <br /> 9R .. City/Stat.00 ,CA ,Laic Phone/� I%--wnr <br /> ���•��• Billabie Partv8eVQ- A?v ff W— Address,?1, 7 7 4v-e- City1State�l��F� Zip/S2- 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 Z;#OF WELLIBORING INSTALLATION TYPE, CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM` 4 OLA:01 BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING OLA: <br /> _❑EXTRACTION:Vaporl Water ❑HAMMER/DRIVEN • CASING THICKNESS TYPE OF CASING: ❑STEEL 0 PVC'❑ OTHER- <br /> _❑SOIL VAPOR PROBE ❑;MUD ROTARY DEPTH OF GROUT SEAL :TREMIE TYPE TO BE USED: ❑,AUGERS E3,HOSE ❑PIPE' <br /> _❑SOIL BORING 0 PUSH POINT(GPI CPT). GROUTSEAL'PUMPED:❑Yes ❑Nd(MAXIMUM FREE FALL DEPTH i5 3o FT). <br /> _❑INJECTION ffeAlrSame.O=m ❑HAND AUGER GROUT SPECIFICATIONS: <br /> ©OTHER: ❑OTHER: APPROX.BORING DEPTH .. ❑BOLTED TRAFFEC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Ria: Casing Depth: Baring Dia_: <br /> COMMENTS: ' <br /> NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED- DESTRUCTION METHOD:(CHECK ALL THATAPPLY) ,/ <br /> #OF WELL($)TO BE DESTROYED p .AVER-BORE DIAMETER OF 10 INCHES TO DEPTH OF ukI' ,S FTS <br /> WELL IDs:/0 W� J 'tiL C�GLLS 1, A4 to Q _ ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE- <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM ro. Fr BELOW SURFACE <br /> TREMIE TYPE TO BE USED; AUGERS ❑ HOSE ❑PIPE ❑MUSHROOM CAP AT L>3 FT) "Fr BELOW SURFACE' <br /> I W 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 /> �r Regulations and all applicable C IlforniaJaws. <br /> Si rigid Yltle/Com an LII�Cr- "�� �A <br /> Print Name r L,� Date' <br /> r DEPART ENT USE ONLY' <br /> SITE MAP IN UNITrIV�FILE- ITE 4DRESS P5WA (} <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTEid BY DATE:ISSUED Z AREA <br /> GROUT INSPECTION BY 'FINAL'INSPECTION BY. DATE <br /> DESTRUCTION INSPECTION BY DATE- <br /> CO MMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC <br /> SERVICE RO# <br /> PE CODES FEE INFO AMT REMITTED CHECK#' RECV'D BY 'DATE: INVOICE- <br /> REQUEST" PR# <br /> 5d <br /> $125x yy 1, 000 - . W1 sR#DOG7i� . <br /> ow <br /> •f+fe•,w <br /> 2900 <br /> C-S7 WC WAIVER -C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 5109112 WELL PERMIT APP <br />