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Pq�)" • SAN JOAQUIN COUNTY • <br />LOP <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />ITE MITIGATION <br />600 East Main Street, Stockton, CA 95202-3029 I <br />••. P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.siciov.org/ehd ��--#"I VCLJ <br />9Cf F 0•i+t�` <br />WELL & BORING PERMIT APPLICATION AJG 22 2011 <br />FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REM <br />ON <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDNMEApplication is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application daaA ly <br />Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. <br />Site Location 119 W. IWL4-S{-, Cross Street RAVIL(tX XWWA_ City 46L Zip ISSIIo APN 7-3311,303 <br />Property 11 ee�t, 1 TTm"�'�� ,y, !� c <br />Owner T�(taet_•K"LM �lnywuldress 4 F_I -0".40 5jl-City S64, Zip /��S,,,Ibz- Phone '1 q-—Z�-yZL31 <br />C-57 Contractor -r .��r Address 7r%� .&2k yF-. City -� Lic Dr�+2) Phone. O <br />Consultant/Sub Cntr G � Address IT(01 4j, 'A"& - City �y� Lic 5�'i�GP3 Phon I 'l -O QJ11 <br />Billable Party ( Address kct OJ, 0,6", (�F. city Zip T0(Q5 Phone 711-08n <br />GIS Coordinates: Y —CLI .4l95-1 2 - <br />SOIL <br />SOIL BORING <br />WELL IDsID_ <br />OTHER s_ <br />TYPE & If OF WELL/BORING <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />_❑ MONITORING <br />❑ HOLLOW STEM <br />DIA. OF BOREHOLE 1:41A ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br />EXTRACTION: Vapor/ Water <br />❑ HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />_❑ SOIL VAPOR PROBE <br />❑ MUD ROTARY <br />DEPTH OF GROUT SEAL 34 _TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE XPIPE <br />SOIL BORING <br />()(PUSH POINT (GP/ CPT) <br />GROUT SEAL PUMPED: ❑ Yes WN. (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />_❑ INJECTION ILe.Air Soarae. Ozone )❑HAND AUGER <br />GROUT SPECIFICATIONS <br />_❑ OTHER: <br />❑ OTHER: <br />APPROX. BORING DEPTH I ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />�4 63 <br />17 S 'q <br />CONDUCTOR CASING No ❑ Yes: Casing Dia: Casing Depth' Boring Dia_ <br />COMMENTS: <br />N K <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />___# OF WELL(S)TO BE UE: <br />WELL IDs: <br />GROUT SPECIFICATIONS _ <br />TREMIE TYPE TO BE USED: <br />COMMENTS <br />AUGERS ❑ HOSE ❑ PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />❑ OVER -BORE DIAMETER OF INCHES TO DEPTH OF FT <br />❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br />❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br />❑ MUSHROOM CAP AT (>3 FT) FT BELOW SURFACE <br />5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />I hereby certi that I ave prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br />Regulation n all ca is California laws. (y� /' <br />Signed �• Title/Company .iitt'K Gc'eu� Sl f <br />Print Name F�1/t L- Date 0/1"7/ II <br />SITE MAP IN UNIT IV FILE - SITE <br />WORK PLAN DATED 14Lt-P- r <br />APPLICATION ACCEPTED D'r -. <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />COMM ENTS/CON DITIONS: <br />DEPARTMENT USE ONLY <br />DATE <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE <br />SECSR <br />REQUET <br />R# <br />PRO # <br />INVOICE <br />a%O� <br />$l x I <br />LZS <br />lo8d <br />d 7-3 ag[i <br />sR#40063373 <br />�4 63 <br />17 S 'q <br />3 7� <br />row <br />N K <br />(300 <br />P 900 6f3 6S 61 <br />C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />EHD 29-01 07128/10 WELL PERMIT APP <br />