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SAN JOAQUIN COUNTY <br /> Z� ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> N. 1 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> `� - :p�• Telephone:(209) 468-3147 Fax: (209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> 9�iFOR�� <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 /> tEtjs <br /> Site Location S'. L%'c'P Cross Street f r t 1.P. City/Stale Tbf(r% Zip 9f330 APN /4/-ZI - 02--' <br /> Property <br /> Owner / I Address 1,06,�A,Vr4eno <br /> d i„-of <br /> �Me-SaT City/State L <br /> n)t•hi Zlp OO—P Phone 51U-601 -3707 <br /> C-57 Contractor Address UcFL <br /> CrIIlc,Dr. city/state )f -kin Lic Zc90 Phone GUS—y X00 <br /> Consultant/Sub Cntr [-1Vr�L Address �G�A),V-1;?Afg, gn A City/Stale Lic A)IA Phone2G9~� <br /> Billable Party �N�c'� Address City/Slate Zip !I Phone <br /> GIS Coordinates:X .��,UZ�w Y ^l2/,50�f 1_ r <br /> ��. �3 2 2,IW N <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <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 ❑HAMMERIORIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION Ii.e.AirSoarrie.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑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 W ELLIS)TO BE gESTROYED .]OVER-BORE DIAMETER OF INCHES TO DEPTH OF_j-Fr <br /> WELL IDs: — (� �/ [:]PRESSURE GROUT TO DEPTH OF Fr BELOW SURFACE <br /> u <br /> GROUT SPECIFICATIONS F _6.4 _ M P•'if ❑EXPLOSIVES FROM TO Fr BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE E.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 ON I have prepared this application and that the work will be done in accordance with San Joaquin County Or nances,Rules and <br /> Regulations,and-all applica California laws. <br /> Signed �C� �/1Title/Company r I e.4t d Jc ��'��/Jf '-� <br /> Print Name <I C nr'� Date l <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS S POgQ.T<)fu 44Ty20� w <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE EA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE S Z2-ly <br /> rr <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> L1 REQUEST PR/# <br /> $125x Cl(�T J X21 I SR# �cp <br /> RO# <br /> 3500 <br /> PR# <br /> (2900 <br /> C-57 ✓ WC WAIVER /1-144 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC _ <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />