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\,ow <br /> �o. E.co \\ SAN JOAQUIN COUNTY 4 i <br /> ,3 ENVIRONMENTAL HEALTH DEPARTMENT SITE -0? <br /> �- <I E MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:wwvv.sictov.oraiehd <br /> WELL & BORING PERMIT APPLICATION o <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. /O <br /> _ aSite Location�� 4• F�'r'✓ Cross Street &.Z4 A,1 } City `�`t`���f�'�'� Zip_��- � APN <br /> Property., <br /> Owner ST Address City Zip L} d1 Phone <br /> Ift <br /> �f <br /> C-57 Contractor 4t tJ Address �rLCaC1 + cityJ`r �'��h� Lic Phone <br /> Consultant/Sub Cntr Address 3,56ci /Zb City Phonea�� c' as <br /> Billable Party ,, = 7✓e" 'e-tt Address psi City Zip Phone <br /> GIS Coordinates:X Y ..--12-1.z06 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGEP..OTHER) <br /> ❑SOIL BORING IDs <br /> IS WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> O❑MONITORING OLLOW STEM DIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> XTRACTION,Vapor! at'e' HAMMER/DRIVEN CASING THICKNESS .. TYPE OF CASING ❑STEEL 4 PVC ❑ OTHER <br /> _[J SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL t 7 TREMIE TYPE TO BE USED ❑AUGERS,S�OSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS \ \\ <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ,53 &[-BOLTED TRAFFIC BOX OR ❑STOVE PIPE \1 <br /> CONDUCTOR CASING®No❑Yes:Casing Dia: Casing Depth Bonng 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(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF-FT BELOW SURFACE t <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L>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 ��- <br /> red this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all . <br /> Signed Title/Company <br /> Print Name 174T ego Date <br /> DEPARTMENT USE ONLY �P- <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED a <br /> APPLICATION ACCEPTED BY DATE i O d AREA <br /> GROUT INSPECTION BY FINAL INSPECTION `°` s°.f DATE <br /> DESTRUCTION INSPECTION BY DATE fa r & <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# G FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE I SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 350 , $12 X 1 -4 I2s.• SR# 003U <br /> 350' <br /> kA- 3�s �.� g rL 1 (30 0) 59 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 WELL PERMIT APP <br />