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0.?'a �•.c SAN JOAQUIN COUNTY ORIGINAL <br /> ). ..yet •.OG <br /> ENVIRONMENTAL HEALTH DEPARTMENT Lop <br /> y MITIGATION <br /> ITE <br /> •'•'�`� :�•1 1868 Hazelton Avenue, Stockton, CA 95205-6232 o -- <br /> ..-. . ../ <br /> Telephone:(209) 468-3147 Fax:(209) 468-3433 Web:www.sigov.orct/� - <br /> \�FpR <br /> WELL & BORING PERMIT APPLICATION FFR 1 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION 2014 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRON <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application 5"W <br /> 'n� Wan <br /> Joaquin County�g�09ent Title, Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. MFS <br /> Site Location ►►/�ue�ofaP/.s �/. Cross Street 5- Tu/s a flue. City/State S�oc%/o., Zip �S�/S APN /D 3 i/00 S <br /> Property 54. rdAf...,r. <br /> Owner R6/., Wo./rs LA;uw/»etj Address /Flo Ec,s We,, Ave City/State 5�tel-4)i Zip 9.105 Phone('2oy)1169-36Uv <br /> C-57Contractor �ecy�•//�� Address 956 City/State //�.�><i,�zfL/�LicyEs/6S Phone l9lS)Y/3.6302 <br /> Consultant/SubCntr Address cCow� c til. City/State U / A-ic A Phone CS30)�7�-y�ov <br /> Billable Party Address 91111 City/State Ga++ Zip `?S 9V? Phone (f'3u);L72-/X00 <br /> GIS Coordinates:X Y —(21, /(00(7 <br /> C NSTRUCTION WO TO BE PERFORMED: <br /> NEW WELUBORIN (CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORIN s CPT- / <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑��MUD ROTARY DEPTH OF GROUT SEAL/i�"190 7 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE EfPIPE <br /> _LI'SOIL BORING IaPUSH POINT(GP/CPT) GROUT SEAL PUMPED: E�Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i e Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH AW ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING of No❑Yes: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,and a pplicable California laws. <br /> SignedTitle/Company o ec f Scree t� <br /> Print Name AG//GA1 OytNv.+ Date a 6 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS ('off 2oJ-b .15 R� <br /> WORK PLAN DATED 4 b <br /> APPLICATION ACCEPTED BY 0gie, -A DAT ' AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BYQpa-k ti^ --HATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> Q p Z-/0- REQUEST PR# <br /> 2 l O S $125.( 7 ct evG�N � 7+O( ''// <br /> SR# q0 (P <br /> 375" RO# <br /> (3500) <br /> PR# <br /> (2900) <br /> C-57 (/ WC 1-1 WAIVER AJ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT I/ ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />