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ORIGINAL <br /> 5�1'Ih <br /> y SAN JOAQUIN COUNTY RECEIVED <br /> . ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> { JUN 0 9 2014d� <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 -SITE MITIGATION <br /> od�•P. Telephone:(209) 468-3147 Fax.(209) 468-3433 Web:w—�Q 'Q HEALTH NIT IV <br /> WELL & BORING PERMIT APPLICATIONMIT/SERVICES <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 bb?,-3 Pbu:Lt -r,✓A-w-e- Cross Street 2940"i,� F614-Q- City/Stale C A C�ip 252-0:7 APN Dcn-410-L <br /> PropertyLIncOlrl 'pyp�Yt1/S lid f ���]]} <br /> Owner GIyondLut! ttt l Address i�px `I(o 1 I City/StateZiip ( D Phone <br /> C-57 Contractor (\ f101Q - Iv <br /> WP Address 2M,16 6. AL;-o S-� City/State�["Cl c%1109S Phone 930'(y(0�9 <br /> Consultant/Sub Cntrs"1-an-htC Address3pri "po t� a UFj'Rk4(X) City/State C is Phone( 4 1 C <br /> Billable Party Address City/State Zip Phone <br /> GIS Coordinates:X - 8&VIy Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> Ekf4EW WE UBORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> OIL BORING IDs_ RE- I , C3� RA-3 <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _[I MONITORING &40-LLOW STEM DIA.OF BOREHOLE <br /> _'A" ❑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 [IMUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> a[R'SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(Le Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> 1 <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH J ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE <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:(CHECKALL THATAPPLY) <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 all applicable.0 rnia laws. <br /> r <br /> Signed Title/Company 5a/ <br /> Print Name A-, / Date C, 2- <br /> DEPARTMENT <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS LV�P �jl /f 1, i ttF <br /> WORK PLAN DATED J t-( -4-/ <br /> APPLICATION ACCEPTED BY '/ Of}Kur� DATE IS �GrT�1 <br /> GROUT INSPECTION BY FINAL INSPECTION BY U-4 k <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 I RO# INVOICE <br /> 4 REQUEST PR# <br /> t V S g 125 x 14 3 ZZj z- A-­'crwr&A- G-Q-t`� SR# 0 <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 ✓ WC ✓ WAIVER rV kg- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />