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:I a <br /> j <br /> ° SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> 600 East Main Street,Stcckton,CA 95202-3029 UNIT IV <br /> -t; Telephone:(209) 458.3454 Fax:(209) 468.3433 Web:www-stgov.orglehd <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRE Q E ISS1-iED <br /> Application is hereo made to San Joaquin County for a permit to construct and/or inytatt the wars:described. This aPPliI is made in co,Ttpilance with San <br /> Joaquin County Deevelupmenl Title,Clraptcr 9-1715.3.and erre Standards of UW San Joaquin County Enylronmental Health De7ertment. <br /> Site LocationVA rr��f� L-' Crass Street - �ifri� /Caa� <br /> � <br /> ,. City „%1 LAPNProperty Owner Address L ZIP r� Phone <br /> C-57 dress �C� qC� <br /> " <br /> G <br /> city /' Uc 7/��'4 -Phone 7en7 .�'rf��� <br /> GonsultantlSsrbCntrJ` �rr _ Addfoss e� Gty�d Uo .Z Phone CGzP-00+c, <br /> Billable Party V;z'k ' r Address �r+rA r� City L r Hca! rp MPOC Phone Oce-��O`' <br /> GIS Coordinates:X 1-71 Q6 Z Y 2 2 <br /> CONSTRUCTION WORK TO BE PERFOROD• <br /> 0 NEW WELLr9O T (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> 7 SOIL BORING IDS <br /> WELL IDB <br /> El OTHER IDs <br /> P &*OFO N INSTAL-ATIPN TYPE 2gIVSTRiJCT10N SPEGF1CA710NS <br /> _CJ MONITORING ID HOLLOW STEM DIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> �[]EXTRACTION:Vapor/W.2ter 0 HAMMERORIVEN CASING THICKNESS _TYPE OF CASING: ❑STEEL C3 PVC ❑ OTHER <br /> ^I]SOIL VAPOR PROSE 1Z MUD ROTARY DEPTH OF GROUT SEAL r�. TREMIE TYPE TO 9E USED: 0 AUGERS b HOSE ❑PIPE <br /> _❑SOIL BORING I❑PUSH POINT iGPI CPT) GROUT SEAL PUMPED:;❑Yes ❑HeF <br /> _0 INJECTION.[,per �13 HAND AUGER GROUT SPECIFICATIONS {MwcIMUM FREE FALL DEPTH 1S 3o FT) <br /> _0 OTHER: ❑OTHER; APPROX.BORING DEPTH I]BOLTED TRAFFIC BOX OR p STOVE PEPE <br /> COMMENTS: <br /> CONDUCTOR CASING Cl tlo❑Yes:Casing Ola; Casing OCPlh: Boring Dia; <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DE 7 LIC I WORK TORE PERFa ME DESTRUCP L <br /> #OF LL(S T BE DESTROYEp OVER"Q DIAMETER OF INCHES TO nEaTtt OF FT <br /> L T SPECT T 1 3 M1rL Jb y„w /� Et C� PRESSURE GROUT To DEPTH DF FT eELOW SURFACE <br /> GROUT SPECIFICATIO EXPLOSIVES FRGm TO FT mcm SURFACE <br /> TREEY,IE TYPE TO BE USED: AUGERS HOSE PIPE 1-1 MUSHROOM CAP AT3� <br /> COAT MENTS�� %o.����l�tza�ntP r �•dila f t1�1 il!' � F78Fi4W SURFACE <br /> ,` '.-'�_•--�• _ <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANC Ef FOR INSPECTIONAPS OIINNTMENTS ^� <br /> I,hereby cortify that I have Prepared this appllcation and that the work WHI be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California laws- <br /> Simed Title/Company <br /> Print Name — <br /> .---- nate <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT rV r!LE-SITE ADDRESS <br /> 'WORK PLAN DATED <br /> APPLICATION ACCEPTED By DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY _ DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: RID# FAC* <br /> PE CODES FEE INFO AMT REMITTED CHECK 9 REGV'B BY DATE S@RV10E RO# INVOICE <br /> RE4UE5TI PR# <br /> 3 122 x <br /> SR# <br /> RO# <br /> 3500 <br /> PR# <br /> WC WAIVER C-57 LETTER OF AUTHORIZATION zsao " <br /> C-57 N TO SIGN PERMIT ENCROACHMENT DOC <br /> EHi�Tsai 07-128110 <br /> WELL PERkirr APP <br />