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op4�l e <br /> AL ' <br /> SAN JOAQUIN COUNTY ORIGIN <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> < t <br /> :.ki a- 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> •. f._.�;P Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.sigov.org/eh <br /> 9�/FOR <br /> WELL & BORING PERMIT APPLICATION OCT 14 2014 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH <br /> PERMITiSERVICES <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 an Joaquin County Environmental Health Department. <br /> Eleo"�k wail 61 P+ Linc 20 �0�+ e-s <br /> Site Location.-205 (8G�� Cross Street Cit ,State Zip APN <br /> Property A <br /> OwnerC,.t'tYynS Ili1��11C 10 Address I,cnG EA4('ka-kr Wow City/State . C4 Zip`� 20 Phone001�`I`�$-?S�{3 <br /> C-57 Contractor GOC-CM ���c� Address (a(o71 A6 S0.S'1V'teat- City/Statel. !Mr�l�U1 Lic 1 0 Phone(42,j)3-71-_eu <br /> Consultant/Sub Cntr Address City/State L!c Phone <br /> Billable Party Address City/State Zip iq%b Phone <br /> GIS Coordinates:X K7.?4y(21'+J Y-121.gV,-71rpUj <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/(BORING,CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> II SOIL BORING IDs CL S 2-. <br /> []WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WEL ORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLEJ.It ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(I.e Air$Parge.Ozone)❑HAND AUGER �" GROUT SPECIFICATIONS <br /> gOTHER:EX P-OTHER:[,^reC f"Pwsk APPROX.BORING DEPTH PO' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CAS NG❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: Cdlfe.cf�n$ sed Q-A& gtm�n G "QngAL1-% Sj&,, IL <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 ElMUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 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 Calliiforr I s. /n / <br /> Signed r� Title/Company �i� Y�/�y � C'nyu <br /> Print Name k4 Date to 4S 4ic/ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS e'-0+ <br /> WORK PLAN DATEDq11 11q , dq <br /> APPLICATION ACCEPTED BYA1!04i@ijZ-- DATE I EA <br /> GROUT INSPECTION BY FINAL INSPECTION BY "MTE <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 /> REQUEST PRp# <br /> Z165' $130X 0 679�Do I;,P� !� I SR# Q O0� <br /> Z�03 31TO 079iy <br /> PR# <br /> (2900 <br /> C-57 ✓ WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 7/24/14 WELL PERMIT APP <br />