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1 <br /> pcL r..� SAN JOAQUIN COUNTY (�E <br /> ,o co ``J <br /> ENVIRONMENTAL HEALTH DEPARTMV/[P nn <br /> E pp <br /> UCT o 5 <br /> 600 East Main Street, Stockton, CA 95202-3029 n �� MITIT vTION <br /> . P <br /> Telephone: 209 468-3454 Fax: (209) 468-3433 Web:vvw� fJ V r N } ( <br /> q�IFOR�� P ( ) IT/SERVICES <br /> WELL & BORING PERMIT APPLICATI <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <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 made in �1plianc with Sa <br /> Joaquin County Developmer)t Till Cha ter 9-1115.3,and the Standards of the San Joaquin County Envir nmental Health Department. CtT'� (d <br /> C'; L o'F S+6C: r t ow W <br /> Site Location ross Street City Zip APN <br /> Property (2;I�r -t 11C Wo r orada - 2- <br /> Owner Address / _p IV City w'TD Zip Pho7te CI <br /> VY Contractor A711-�(N�ej I Address to PrtM /St ��' City a V0 <br /> Li, c��n S Phone S C7 "la <br /> Consultant/Sub Cntr Address S G�LtJ City G Lic Ot/ 7 Phone fir! '70 <br /> rr01 <br /> Billable Party Address S City SEE-6/1 ZipPhone <br /> GIS Coordinates:X 3'I.94 94,i 9,2919 -/sl-1.8 10&070&3 <br /> �75� <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) HLL GUFY <br /> ❑SOIL BORING IDS <br /> "(WELL IDS UZA <br /> ❑OTHER IDs I - <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONSIn <br /> w <br /> MONITORING 7<1OLLOW STEM DIA.OF BOREHOLE X,� MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: r� <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS t` TYPE OF CASING: ❑STEEL)�rPVC ❑ OTHER W <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEALS REMIE TYPE TO BE USED: AUGERS ❑HOSE ❑PIPE <br /> J <br /> _❑SOIL BORING [I PUSH POINT(GP!CPT) GROUT SEAL PUMPED: Yes ❑No(MAXIMUM FREE FALL PTH IS 30 FT) <br /> _[I INJECTION(i.e.AirSaaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS // /�l h� J wHa 12 �41/r'S <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ' poLTED TRAFFIC BOX OR [ISTOVE PIPE <br /> O <br /> CO DU TOR CASING No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: I �RfRrIRINGS <br /> n <br /> NOTE: OFFSITE WELLREQUIRE ACCESS AGREE NTS 04 ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) V <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT b <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT BELOW SURFACE "5 <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 prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all applicab alifornia ws`. / <br /> Signed Title/Company <br /> Print Name M( Ewan Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 3 O I3 5. rz I O Y-a d O S-I r e e+ <br /> WORK PLAN DATED_ ju n e I A . 9—n 1 O <br /> APPLICATION ACCEPTED BY Vi c a r l a 1 A C. C!Q rf-n 2y DATE ISSUED 10 - G -10 AREA <br /> GROUT INSPECTION BY '11&( ri4 7)76da,-I-Y2xt FINAL INSPECTION BY �6Ci�►rJa rYLdCllYrn�-c. DATE/044­00 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: 3 -S1i >7 • ri 2 LS <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> REQUEST PR# <br /> 36'0/ $122x 3 '*36,4 . GO 3/7 i0- -/o SR# 004 11 <br /> 357-63 'Ir34t 00 X44. OD 3 /7/q Ro# / 92 <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 WELL PERMIT APP <br />