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OR I Gi 1� h <br /> °p0.u)N SAN JOAQUIN COUNTY <br /> ? ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> �•. Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehd UNIT IV <br /> ,9�/Fpf�.•�P <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 /> Site Location /Zoo/ S. y Q7 Cross Street 1le62r-,,L (�)4> t' 1`'0'i4dtity/State "[A ip ILU APN Z64(-OHIO-, <br /> Prope / p <br /> Owner N �T1{ Address 12-001 -f ,t w 91 City/State Al f£a4zip Q 3(�Phone 7�— p Z�/-3`OJ <br /> C-57 Contractor�{�n�)tAQ 1� Address ��(7• �O?t 1 Q lJ City/State t0VC)Dc MOLic yt 14160 Phone -S3 D- 7 U) <br /> ConsultanVSub Cntr Address City/State Lic Phone <br /> Billable Party Address City/State Zip Phone <br /> GIS Coordinates:X 310524 Y —I 21. Z2 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IQ,s <br /> WELL IDs M <br /> OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _MONITORING 9HOLLOW STEM DIA.OF BOREHOLE OO) ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL gPVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL_Z!� TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes 19No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.AirSoaroe Ozone)[3 HAND AUGER GROUT SPECIFICATIONS AJ&7- E'n T <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH G $BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING is'J No[IYes:Casing Dia: Casing Depth: Boring Dia: <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 Iall applicable California laws. <br /> Signed 1/�`/��/�__, Title/Company W N�� 1 ✓w�u FC <br /> Print Name ��<_)1 ! Zr�^� 1���,•� �' '�_I <br /> Date 71 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 14 00/ s 99 <br /> WORK PLAN DATED us-T Ol q <br /> APPLICATION ACCEPTED BY J-`� D I�KLw+1 DATE IS� A <br /> GROUT INSPECTION BY FINAL INSPECTION BY t 4 h nA E SS 2�9--/ts/ <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> �;OUS <br /> FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> a REQUEST PR# <br /> Z $125x SR# <br /> ,ZOO ,Lj RO# <br /> (3500 <br /> !bD PR# <br /> (2900) <br /> C-57 ✓ WC ✓ WAIVER /l% C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT // ENCROACHMENT DOC ,4 <br /> EHD 29-01 5/09/12 <br /> WELL PERMIT APP <br />