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OUNTY-WELL-PERMIT-APPL.814N JOAQUIN COUNT Tp'//wWw•sjcehd.com/d f L E df <br /> S�1N J LO <br /> x°1�rft''•P.G <br /> � � - EN ONMENTAL HEALTH DEPART NT ITEM.(T�GATION <br /> r t { CA 95205-6232 <br /> 1868 Hazelton Avenue, Stockton, www aiaov ora/ehd <br /> e•.., ;:.:•:P Telephone:(209) 468-3147 Fax:(209) 468-3433 Web: <br /> WELL & BORING PERMIT APPLICATION MAR 14 2013 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL PEALTH <br /> pplication is made in compll'alR�ef+Nt9 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This a <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmentalal Health Department. <br /> ateTXi � b �W�23 -6O�-��-- <br /> 16 <br /> 6OLIWCHkL <br /> Qb •±+�X 33Ia City/St <br /> Site Location T _ fIZip <br /> -7�(Phone <br /> PropertyPI3 - Address 5011 ST� .N "Tkr cCty/State LT7\ 0Phone(7o_?) <br /> o? 3 <br /> OwnerdG5NCity/State� Tk• Lic <br /> ti[c+ 'VpL,fC, Address 955 V� N75K " 3 Phone �yyN-tfj36 <br /> C-57 Contractor loo Ci /State uIc yqN' SbG <br /> Consultant/SubCntralg o � Address 3418AtCity/StateY� K` Pt2 Phone <br /> -TRL dress 8K o <br /> Billable Party OL <br /> ° <br /> Ad <br /> GIS Coordinates:X�Y� <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> E]NEW WELLBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORINNA INSTALL— CONSTRUCTION SPECIFICATIONS <br /> ❑HOLLOW STEM DIA.OF BOREHOLE � ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _[3 MONITORING CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _C EXTRACTION:Vapor/Water ❑HAMMERMRIVEN DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> Air c Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑INJECTION( ^ ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> ❑07HER:_�--APPROX BORING DEPTH <br /> _❑OTHER:�— Boring Dia: <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: J Gering Depth:__ <br /> COMMENTS: <br /> UIRE ACCESS ESTRREEMENTSUCTION ME OOD ENCROACHMENT PERMIT <br /> NOTE: OFFSITE WELLS &BORINGS REQc �I <br /> DESTRUCTION WORK TO BE PERFORMED: �OVER-BORE DIAMETER DF 16 INCHES 70 DEPTH OFT nePl F I <br /> �#OF WELL(S)TO BE DESTROYED ❑PRESSURE GROUT TO DEPTH OFFT BELOW SURFACE <br /> W ELLIDs: I'IAW-5 �W-4 ❑EXPLOSIVES FROM 70 FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Pof: O R'-'^ ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:9AUGBRS❑HOSEL�PIPET <br /> COMMENTS �o-� <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I herebyiTe�m <br /> his application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulatinia laws. �j CiULO( 15T� qf- SOJk(d 620,f, IAIG, <br /> Title/Company <br /> Signed � ' Date ✓/r/ 0 <br /> Print Name A,-4 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS y C) I x <br /> WORK PLAN DATED N4V/ M&k 2c Zo DATE 11 REA /G <br /> (, o✓�KH n-� <br /> APPLICATION ACCEPTED BY ATE't ev./3 <br /> FINAL INSPECTION BY <br /> GROUT INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY <br /> COMMENTS/CONDITIONS: <br /> FAC# SERVICE RO# <br /> ACCOUNTING ONLY: AID# REQUEST RECV'D BY DATE PR# INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK# <br /> 53LG �'varurEa 3-fH-f sR# G79& <br /> 2.qo Z s1z5X 3 Ro# <br /> 3500 <br /> ,t9p�j 37� PR# 3/111312:411 <br /> of 2 2900 <br /> ZIA <br /> 0-57 t/ WC WAIVER All I� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _�.-_ENCROACHMENW I I PFR <br /> FHnPR-n+ vnan� <br />