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lan <br /> SAN JOAQUIN COUNTY MAY 15 2013 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-(5 '�2 SITE MITIGATION <br /> eLkuo:.i. _.:. UNIT IV <br /> gCiFp'tt c� .. <br /> Telephone. (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.ora/ehd <br /> WELL & BORING PERMIT APPLICATION <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 compliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> C <br /> f ("i <br /> Site Location Cross Street D-e t 54, City Zi $2D& APN #W1tProperty <br /> Owner 6// Address zv <br /> �-w J <br /> City STL�� "/" Zip SII Phone 201137-91 <br /> C-57 Contractor 1' �1, �'l� t 9Address Y11i� C;r City (t(1L'N Lic �-3 110 Phone 11(0` X3`9-if 01 <br /> Consultant/Sub Cntr 2Uv' r utf„1 'NW�Address??, (y r1 �Itlz <br /> City, -tY 4ri1 Lic ISL _Phone,5r 9-&XIW 7 <br /> Billable Party–56h t Address) rw+wA Cit Q�r'�✓l P Zip 9109 Z Phone <br /> GIS Coordinates-X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> WELL IDs MW-b,Eyly;- /ytytl_yt <br /> OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> L MONITORING �HOLLOWTEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIAEXTRACTION:Vapor!Water RIVEN CASING THICKNESS i l <br /> TYPE OF CASING: ❑STEEL PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE [I MUD ROTARY DEPTH OF GROUT SEAL _TREMIE TYPE TO BE USED: AUGERS [HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT I CPT) GROUT SEAL PUMPED- Yes <br /> -•y No(M XIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e Air Soaroe Ozonel❑HAND AUGER GROUT SPECIFICATIONS 1`�Lil C kI <br /> _❑OTHER: F_]OTHER: APPROX.BORING DEPTH q5t BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING�0 No[IYes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <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 WELL(S)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 prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,an all ap licable California Laws. J <br /> Signed Title/Company (J(10,1t(I1 of y/ - �+>ZS ✓lbi,;,y+ .yl�yJ�T/��i <br /> tt.� ✓'-i <br /> Print Name S Lr { 9 i Date <br /> DEPARTMENT USE ONLYD <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS <br /> WORK PLAN DATED L 2b0 <br /> APPLICATION ACCEPTED BY DAT U D < < AREA <br /> j� <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE 7)z <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY. AID# FRECV'D <br /> C# <br /> PE CODES FEE INFO AMT REMITTED CHECK# BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> $125x 7 Vz— 11 K- V7 Zd(3 SR#OD67 /(o S' <br /> RO# <br /> 3500) <br /> PR# <br /> 2900 <br /> C-77 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />