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FILE COPY <br /> �o. �.co SAN JOAQUIN COUNTY <br /> ry � :y ENVIRONMENTAL HEALTH DEPARTMENTLOP <br /> N j �IqffIGAT[ON- <br /> ,0:1116 <br /> ON <br /> = ' •'• 600 East Main Street, Stockton, CA 95202-3029 I ,1 .� } <br /> �4..-�..:..-�� Telephone: (209) 465-3454 Fax: (203)468-3433 Web: www.siaov.or+�,lehd <br /> c,r o <br /> WELL & BORING PERMIT APPLICATION Uk(; 2 9 2010 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REME � <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDpR � ` HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is made in cozptTaan <br /> Joaquin County Development Title,,Chapter 9-1115.3,and the Standards of the San Joaquin County/Environmental Health Department. <br /> Site Location to ross Street i 5����' Cell City Tyr � � Zip / �C` APN 13 <br /> Property /J / <br /> Owner ,&A.w�4/.r/C�E?L Address �/�3;/� f' /�YIC I City 4>7 K' �T`�7 Zip ��J- �!�Phonele,j� ��� 2��/� <br /> �/e!lllew-J 01,/�zA ddress A e,[min zu '� City �l' Lic '710-71?' Phone ;4' �'� j 2c) <br /> C-57 Contractor //�� f / 7 .77 'f <br /> Consultant/Sub Cntr LLQ G ��,�AddressCity /�/ Lic 1�'C D '.�Phone �� <br /> Billable Party GL r x f�s�' / _ Address / c I. f� City u�--`­/(/�1 /Zip --� i--Phone iz,C-4< Z-R" <br /> GIS Coordinates:X34�R(p} Y" `I21z ® I <br /> C NSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> WELL IDs_ _ <br /> LJ OTHER IDs 09 <br /> II TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 0414 <br /> _❑MONITORING � �� <br /> ©HOLLOW STEM DIA.OF BOREHOLE.?� ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING D1A: <br /> ❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS SW TYPE OF CASING: ❑STEEL PVC ❑ OTHER <br /> SOIL VAPOR PROBE .❑MUD ROTARY DEPTH OF GROUT SEATREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> i <br /> _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes ACNo(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> i <br /> _❑INJECTION di.e.AirSoaroe.Ozone)XHANDAUGER GROUT SPECIFICATIONS / <br /> _❑OTHER: 0 OTHER: APPROX.BORING DEPTH Fa e'E'/ BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> /� CONDUCTOR CASING❑No❑Yes:C ing Me, Casing De h: Orin Dia: <br /> COMMENTS:-­ <br /> NOTE: <br /> r;"� be ka : g <br /> i <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(S)TO BE DESTROYED - ©OVER-SORE 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:0 AUGERS ❑HOSE 0 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 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all app' le 6elifornia laws. / <br /> Signed Title/Company <br /> Print Name <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT EV FILE-SITE ADDRESS <br /> WORK PLAN DATED 7 p <br /> APPLICATION ACCEPTED BY %gAT AREA d6 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE I-&-W <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITfONS: _ <br /> ACCOUNTING ONLY: AID# FAC <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE 120# INVOICE <br /> �o REQUEST PR# <br /> 0 $12HZ- Z �ZISR# <br /> 350 3 3O RO# <br /> 3500 <br /> 61 D. PR <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PER ENCROACHMENT DOC <br /> EHD 29-01 7128110 <br /> API <br /> FILE CO? <br /> V{v <br />