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� I <br /> SAN JOAQUIN COUNTY <br /> JA <br /> Q FILE COPY <br /> a ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 no <br /> • �4� .::.�;:a. Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.siclov.orgle <br /> FOR <br /> I c� WELL & BORING PERMIT APPLICATION ��L 9 2010 �� <br /> 1 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NNMF �QLrJ�RDW <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is RUM <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. t+ <br /> Site Location J�j'7& (c= � ��`� y�.� �. <br /> epi c•- Cross Street /i�iSf/ i City �7�"� �/ 7 Zip �7 ��r APN <br /> Property - �Ln - c�,�_��` •'II <br /> Owner_S4A(Jp0q .0^1 �1 Address �$!D E. 4ZEr��r� Cite SObcX-Po.�. Zip �a phone C V&F30-" <br /> fI� Y <br /> C-57 Contractor(SLY•cry(), 11 Address t j �7�b City '}c� L�3 Lic 7/ 7�j Phone 7�� <br /> Consultant/Sub Cntr .� gddress '�E, /x i;` ' { Cit a�C° ; f :R;7 <br /> ( �"� y l/epi Lic 7 tPhane . rte. c~� r <br /> Billable Party LLQ" v,/ 6;;, -GAS_ Address ! - ,rel: City Zip 1%a! Phone <br /> GIS Coordinates:X ��� Y_ <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING!Ds <br /> WELL IDs S t` <br /> OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 01 <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2ZLf❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor!Water ❑HAMMERlDRIVEN CASING THICKNESS .SCb'/0 TYPE OF CASING: ❑STEEL KPVC ❑ OTHER <br /> SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL ✓ TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.Air Spam e.Orone1 tXNAND AUGER GROUT SPECIFICATIONS <br /> _E]OTHER: [IOTHER: APPROX,BORING DEPTH 6 -FR- 'KbOLTED TRAFFIC BOX`OR ❑STOVE PIPE <br /> < COUCTOR CASING oYes:Cas�ing ia: Casing De Boring Dia: <br /> COMMENTS:S6. G ! <br /> eff- [m! <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 WELLS)TO BE DESTROYED *. ❑OVER-BORE 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:❑AUGERS ❑HOSE ❑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 prepred this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all ap��WCaWwnla laws. <br /> Signed C Title/Company <br /> Print Name Bi Pie!' Date Jf. lam'/G <br /> DEPARTMENT USE ONLY Q J <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS r d IV �L <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY Dfµ fMz t77=i AREA [1\ <br /> GROUT INSPECTION BY FINAL INSPECTION BiFrDATEI�IZ <br /> DESTRUCTION INSPECTION BY DATE Of <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 356I s122x3 366. t-ZI-In SR#0CQ 72S U <br /> 35fl3 4-(v RO#.: <br /> 3500 <br /> PR# <br /> • 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PER ENCROACHMENT DOC <br /> EHO 29-01 07/28110 WELL PERMIT APP <br /> FILE COPY llooew0 <br />