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• SAN JOAQUIN COUNTY �► FILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> b... < <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> B• P Telephone: (209) 468-3147 Fax: (209)468-3433 Web:www.siaov.oralehd N Wu 1 e <br /> (IFOM1� aN! <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIONOC I 1 ,5 ZCI I�_ <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 AN W"IVIEdeW FIFALTM <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environ ental Health Department-PERMIT/SERVICES <br /> Site Location 109H$ COMCa li �ross Street S -Tui SSG AVQ. City/States}acK n Zip0157.t IS APN 1031\005 <br /> PropertySo' 3�p�y\n Govn u - <br /> Owner P yb\".e W o Dies 'ne4+E• Address IB1b Ea-.# KatGl}on flue City/State S�oG }en Zip95x.05 PhoneA'.09 X68- 3U01 <br /> C-57 Contractor COsc.<& Address ?631 0-e� 0ro/6 City/State Q—Je .�.(ric 9?$//o Phone�9�6�638-/169 <br /> Consultant/Sub CntPr+e 5 eeyu Cecs address�1NN fA 0.1 s�'„NCitty/States .n.se V \Whit Phone 3o)a� - L-\W <br /> Billable Part7/SL.e Saveee (rro�? AddressA%k 4 ecity/Stale(xSaLs *\Ia,Zip S Phone 0 <br /> GIS Coordinates:X Y <br /> ONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> SOIL BORING IDs '5V,-1 - 5A_1 <br /> ®WELL IDs M - W - -+ <br /> ❑OTHER IDs <br /> (1 <br /> TYPE 8#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ki &MONITORING HOLLOW STEM DIA.OF BOREHOLE D ❑MULTIPLE CA INGS D MULTI-LEVEL WELL CASING DIA: <br /> _D EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESSrl t TYPE O CASING: ❑STEEL KPVC ❑ OTHER <br /> _D SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL +CJ TREMIE YPE TO BE USED: CR AUGERS D HOSE ❑PIPE <br /> 3 ($SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes D No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _D INJECTION(I aIr a O,onellr^pjepe O,one)Soep}�}e ozone)El HAND AUGER GROUT SPECIFICATIONS <br /> _D OTHER: ❑OTHER: APPROX BORING DEPTH I U 0 ['BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING D No D Yes:Casing Die: 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 DIAMEER OF INCHES TO DEPTH OF FT <br /> TELIDs: ❑PRESSURE GROU 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 Al (>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 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all applicable California laws. <br /> Signed Title/Company <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS O CrOptz-Q <br /> WORK PLAN DATED Ubu -r OI /+ <br /> APPLICATION ACCEPTED BY ��o�jca� DATE SUED AREA dh_g <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COM MENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE, SERVICE I RO# INVOICE <br /> �1 [' <br /> REQUEST RPR# <br /> n O $125, 2- <br /> CS <br /> 125x ,25 IzS Gs8� S <br /> X90 3 37S 200 <br /> C-57 ✓ WC ✓ WAIVER jVt4- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOc A.Al• <br /> EHD 29-01 5109/12 WELL PERMIT APP <br />