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RECEIVEb <br /> MAY <br /> SAN JOAQUIN COUNTY RIGINAL <br /> E'NVI� ENTA HEAI:THOEP RTME= ENTft <br /> n. E jW T PI~ H <br /> t r <br /> Telephone: (209) 468-3454 Fax:(209) 468.3433 Web:www.siaov.or41ehd. <br /> WELL & BORING PERMIT APPLICATION <br /> FCR WEiJ_S AND BORINGS USED FOR-CONTAMINANT INVESTIGATIONS AND REMEDIATION_ <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROWDATENS-RUED <br /> A7f4ication is he"macre to San Joaquin Covrq for a permit to construct malar install the work described. This app1i*Eon i;made in=npNance vAth Sart <br /> Joaauln County Development Titll!e,Chapter 87115.3,end the S*Wutds of the Sen Joaquin County Envft!omnt:ntal Health Department. <br /> Site Location � Clc.r1 (74A cross street IlAq— /C_ City g.!< rA ZIp. 15261/ APN 12-3-1V-01. <br /> Property <br /> Owner j7?¢1-�. ! Address 147Z �Go�x City&a <br /> T�Y � f*� Tip zCi Phoneme �� <br /> C-S7 Contractor ,411mr,%�cs+,���h`I�/{Si4ddress L 1�_----- ^T City 7flPL�2 L-:1 LIC .Phone 70.7- -7 73 -4e, <br /> GO[tsultanVSub Cntff �^rr:.Co , Address �T� != l��3s .- City e 1,e:,z ,.-,.r Lir�„Z-Phone 1;G�'�Gc <br /> 8€IIa61e Party fiG�Ie.n_G —F ;_ Address _13�piu� Giiy 4Yc Zip Phvri9 SJR` <br /> GIS Coordinates:x7.91.7 Y-I XL 32 2 <br /> CONSTRUCTION WORIS;O BE PERFORNQ?; <br /> [J NEW WELiJBDRING(CGT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> I]SOIL BORING IDs <br /> 1]WELL 109 <br /> 0 OTrIER IDs <br /> TYPE&9 OF WEk!AgPJyQ INSTALLATION TYPl= CONSTRUnDIN SPECIFICNnONS <br /> ____©NIONmORING Ej HOLLOW STEM DA..OF BOREHOLE D SJULTIPLE CASINGS©MULTI-LEVEL WELL CASING DIA- <br /> _O EXTRACTION:V>poH%Vater 13 HAMMERiORIVEN CASING THICKNESS �TYPE OF CASING: 1]STEEL C!PVC-0 OTHER <br /> _O SOIL VAPOR PROBE ❑MUO ROTARY. DEPTH OF GROUT SEAL REWE TYPE TO BE USED: 0 AUGERS ❑Hosc.Q PipE <br /> _O 301 GOARIG p PUSH POINT rGPJ CPT) GROUT,SEAt PUlIPED,0 Yes ❑No(MAXMIUM FREE FALL DEPTH IS 3t)FT) <br /> `0 INJECTION(I.e A Snalgo.omnr5 C)HAND AUC-tR GROUT SPEGIF#CAT10M5 <br /> _,.,CO OTHER: Q OTHER: APPRO)GBOFMG DEPTH Q BOLTED TRAFFIC SOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING Cl Ilo p Yes:Casing Dia: Casing Oepth: 13odw Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACFIMI=NT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: 9CSTRUC33SRI 14gjHOD!(CHF1111 <br /> APP <br /> 900 U.( TODE DESTROYED OVER-BORE DIAMETER OF erCHESTDDEPrKOF FT <br /> V Ds: -1 fr1 1 hKu? Hlw Ihlrs law /� U PRESSURE GROUT TO VEPTH OF €T$Stow SURFACE <br /> G)ROUf SPECIFICATIO v7 p EXPLOSIVES FRou 70 '. FT PELOw SLwFACE <br /> TREMIE TYPE TO BE USE UC <br /> HOSE J&PJPE f1 MUSHROOM CAP AT L>3 FT) FT BELC'N SUR=ACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS: <br /> .1 hereby oortify that 1 Ila prepared this app[icalion and that the work will be donb hi aiceotclance with San Joaquin County Ordinances,RUIes and <br /> Regulations,and a Ira>10 California taws. <br /> Print cams <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNrr.IV nLE=srrE AowgESS e <br /> WORKPLAN DATM l <br /> APPLICATION ACCEPTED OA <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION'BY _ DATE <br /> COMMENT5ICONDITI ONS: . . <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES flw INFO AMT REMITTED CHECK# RECV'O:BY DATE SERVICE RO V INVOICE <br /> REQUEST' PR <br /> 3 ao ' <br /> PR# <br /> Do <br /> G-57 WC WAIVER C•57 LETTER Or AUTHORIZATION TO.Sim PcRmIT ENCROACHMENT DOC <br /> EHO 29-0f 07x22110 WELL PERMIT APP <br />