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Ul Saw JOAQUIw COUNTY �r / <br /> .,„ ..o <br /> w: <br /> 'z ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> :P Tele hone: 209 468-3147 Fax: 209 468-3433 Web:� - s3. °. ��1 ; ti' UNIT N <br /> / n r � <br /> WELL & BORING PERMIT APPLICATION <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 cbrl ? Cross Street 7:/ City/State S r"� ZI'p <br /> Property <br /> Add3Gz� /0e6& Cr i< �City/State <iz�7�iyZ��q�, Phone Z¢r. <br /> C-57 Contractor \/'*1'. D2/l4f�i4ddress != L��t: Cf�r� do 1'"City/State -�tr­�--14E11jc - Phone T AS' 'Vcot 774---o <br /> Consultant/Sub Cntr V OC-12 4MIP1 Address 4-%' /Z00ty/State 06"rFP v 85 Phone <br /> Billable Party Uf-6-)Z /45—,✓7 Address 5,` City/State Zip Phone <br /> GIS Coordinates:X -% 'eFcy Y <br /> 3 7 9 s K(q —/21. 2805/4 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE.HYDROPUNCH.HAND-AUGER.OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASINGTHICKNESS 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(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION[i.e A r Soarae-Omnet❑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: NElBT ��/� /!!1 trf2yu! A.b �6csTntic?L <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY2rr� <br /> #OF W )JOB Dr= OYFD ®OVER-BORE DIAMETER OF t '4r CHES TO DEPTH OF J�pta Fr <br /> Ds: <br /> WELL I — �'� VM 9'f•"' I PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO Fr BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑p HOSE ❑PIPE ❑ �U��p OM CAP AT(>3 FT) FT BELOW)SURFACE <br /> COMMENTS VT l '` V M$ PR 55umira wr w irtt mt,6#�aomm �D�' �4 rn�as i2rtl,K/0 2L*L .,� <br /> 5 WORKING DAYS NOTICE REQUIRED(AF'T'ER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I h ve p pared thi application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all plicatil all is laws. <br /> Signed 'Cj Title/Company C F <br /> Print Name /7 L%2`'`�' Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 0::0C M9/N 5�T,J1604?Z)OV <br /> WORK PLAN DATED JCA(-,Y 7- 1 Zr�/`/ (:gt-r .. _� <br /> APPLICATION ACCEPTED BYDATE IS 16 Fy <br /> GROUT INSPECTION BY FINAL INSPECTION BY C = IWE <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 PR# <br /> O z $125. / I375Q6urv790_ 7 ZS -IY SR# G:> 18 <br /> zea 375 3's � (300 <br /> PR# <br /> (2900 <br /> C-57 WC WAIVER—ova C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT Doc <br /> EHD 29-01 5109/12 WELL PERMIT AP <br />