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• SAN JOAQUIN COUNTY • A d 0 3 3113 <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street,Stockton, CA 95202-3029 ITE MITIGATION <br /> 4 <br /> Telephone:(209)4683454 Fax(209)4683433 Web: www.s' ov.o <br /> r/FURa <br /> WELL & BORING PERMIT APPLICATION a 2012 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REME I <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EWRONMEfd-��� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application IgQq %'J�},c6*WUk11an <br /> Joaquin County Development Title,Chapter&1115.3,and the Standards of the San Joaquin County Environmental Health Depa [ JJ�CCFHH(VVV�II E$ <br /> Site Location 23987 N Highwak s9SU t Jahent J26f ClyAcampo Zip 95220 APN005-170-07 <br /> OwnProer Kupka <br /> Address PO Box 10 c Acampo ity Zip_95220 phone 369-9126 <br /> C-57 Contractor AGE Address 837 Shaw Road cry stockton Lic 680227 Phone 467-1006 <br /> Consultant/Sub CMr Address City Lic Phone <br /> Billable Party AGE Address 837 Shaw Road Cit toc ton Zip 95203 Phone 467-1006 <br /> GIS Coordinates:X Y 1: n r, fjfjnV <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLBOMING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDS <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE 8#OF WELLBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> _0 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.a Aa Srwge_0. ❑RAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> A rova 1 1 e t t er 11/0 B/1 O CONDUCTOR CASING❑No O Yes:Caving Dia: Casing Depth: Boring Dia: <br /> COMMENTS: PP <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 IN HES TO DEPTH OF FT <br /> WELL IDs: NW-3 ®PRESSURE GROUT To DEpTR OF 8b FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Portlana ❑EXPLOSIVES FROM TO FT BELOW SURFACE W <br /> TREMIE TYPE TO BE USED:❑AUGERS [HOSE ❑PIPE 12 MUSHROOM CAP AT L3 FT) 3 FT BELOW SURFACE .Q <br /> COMMENTS 00 <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,an�d�/T11 applicable omia laws. <br /> Signed (0JI-- :� _ Trle(Company Geologist / AGE 1� <br /> Print Name William Little Date 02-10-2012 �- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS -2 3 r <br /> WORK PLAN DATED Fe ry 201m2- <br /> APPLICATION <br /> D12APPLICATION ACCEPTED BYDATE IS - / S <br /> GROUT INSPECTION BYjra&p FINAL INSPECTION a u"TION BY E <br /> DESTRUCTION INSPECTION BY Oc`K�` DATE p,49-1? <br /> COMMENTS/CONDITIONS: ZS <br /> ACCOUNTING ONLY: AID# FAC# \� <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE l3 <br /> REQUEST I PR# <br /> :350 - s, ( / .2 (7D SR# 066435 ° <br /> ?S03 37n 37�: � _ ROoo <br /> S, (088 <br /> xy� <br /> ViC WAIVF_R C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT --------ENCROACHMENT DOC <br /> WELL PERMIT APP <br />