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oRq�ty c SAN JOAQUIN COUNTY <br /> CRIGNAL <br /> �: . E•.o <br /> y � ENVIRONMENTAL HEALTH DEPARTMENT <br /> Q: a <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 I TZpN <br /> UNIT IV <br /> Telephone: 209 468-3147 Fax: 209 468-3433 Web:www.sigov.org/ehdr� <br /> 28 Z014 <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND RffMVf6l®WMffNTALHEALTH <br /> NON-REFUNDABLE PERMIT FXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 of1the <br /> ,1San Joaquin County Environmental Health Department, <br /> Site Location 2 q �`�`" Cross Street { leo/ City/State-Tr"g4 A Zip9��-(_ A P N <br /> Owner 661(�&AVILl4..., Address 126A. City/State Zip 9S31lo Phone <br /> C-57 Contractor A OA\ Address (-'-1)Tlh OtAI City/State Lic C Phone91ty-V&?-?C�2 <br /> COnSUltant/Sub Cntr Corte dress l l�9 Tvuet.e.Cuvlw QY. City/State <br /> Lic� honeQQ��.�D-Uy"(-�-{�� <br /> Billable Party far . a Address G City,State Zip -MPhone_I - <br /> GIS Coordinates` d �� Y to '� <br /> ' 7 37y.2 -124 Si3o <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> r-NEVv-rLL/BORING(CPT C-4~AF HYDRnw INCA,HAI�V J-AUGEP OTHER) <br /> SOIL BORING IDS <br /> ��IVELL IDs <br /> OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> . (vIONITORING OLLOW STEM DIA.OF BOREHOLE .LL" _ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_2� <br /> _❑EXTRACTION:Vapor/Water [7 HAMMER/DRIVEN CASING THICKNESS '[y TYPE OF CASING: ❑STEEL $(PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL-alt TREMIE TYPE TO BE USEDNAUGERS ❑HOSE ❑PIPE <br /> SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED: ❑Yes 4kNo(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION(i e Air Soarge Ozone)❑HAND AUGER GROUT SPECIFICATIONS_ <br /> _❑OTHER ❑OTHER: APPROX.BORING DEPTH_�� ❑BOLTED TRAFFIC BOX OR STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth___ Boring Dia' <br /> COMMENTS <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> ____#OF WELL($)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: [3 AUGERS 1771 HOSE I_] PIPE [D MUSHROOM CAP AT(>3 FT) —FT <br /> 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 /> Regulatio n a b California laws. c- <br /> Signed Title/Company .S("VL1 <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 2 q( .S s y�g wSFnJ fZola —C'o2r�sS RA�'C'+y <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY �_�DI�K�tvvl DATE EA��G49 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <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 /> REQUESTp PR# <br /> Ila f $125 x I — v� C6a1vr-4P S- -1A, sR# <br /> z90 37_ RO# <br /> (3500 <br /> PR# <br /> 2900 <br /> C-57 ✓ WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT (i ENCROACHMENT DOC /y <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />