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L__I V GV <br /> JUL 11 2 <br /> � SAN JOAQUIN COUNTY LOP <br /> TE+ pully <br /> 'Op..•" .CpG <br /> ENVIRONMENTAL HEALTH DEPARTME IRONMENTALHEA TMNIT IVTIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 PERMIT/SERV! <br /> • oq`;FOR��P Telephone: (209) 468-3454 Fax <br /> (209) 468-3433 Web:V1IWW.s' ov.or lehd <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 9 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 /> t� c cross Street Al. SA Ox W. CityS` OCA-41 zip 9 VGS APN / 3 0c <br /> Site Location �-1 L• -Jt• �' - <br /> Propert ((T1 ' r <br /> Owner e -e tOrr�,� r/ InrAddress �g(Jfl L f�2,Y+Gp�-tet_ City-�I VVN 'i Zip S�G] Phone:a09-q94--r1_1� <br /> C-57 Contractor Crt c,S��n/I �[. 6) Address � s r ls�G City ��G/` - Lic 3% Phone�03—!551 <br /> Consultant/Sub CntrAAATG rtSSG�Tsa-fes Address/P-7 LLw_ �l P+ A,�w 5+��26ty UAB 3-0 Lie Phone 9C41_S 1`i-22ZJ <br /> Billable PartyATG /C5S0U 1u*0 Address j� G Unn.Pti!'m fIII Sltf amity Zip 1 Phone GIs Coordinates:Coordinates:X Y <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 WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _E]MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑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 Sparge,Ozonel❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING ElNo❑Yes:Casing Dia: Casing Depth: Boring Dia: <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 �INNCHES TO DEPTH OF FT <br /> WELL IDs: W IBJ l f w PTRESSURE GROUT TO DEPTH OF J FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE IPE USHROOM CAP AT L3 FT) `1i FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that! ve prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulationsd al pli a Ca' is laws. <br /> Signed Title/Company fr,'� <br /> Print Name a.e\ Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS Z,;9_0q S <br /> WORK PLAN DATED -+-I x/I r <br /> APPLICATION ACCEPTED BY � «t� DATE ISSUED -411-2-111AREA <br /> GROUT INSPECTION BY FINAL INSPECTION 13Y ,�- DATE$JS I II <br /> DESTRUCTION INSPECTION BY DATE — 7--r_T <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> itREQUEST PR# <br /> 35'OZ $122xta -Nlitzd,00 o Sf66� <br /> SR# <br /> 3 sa3 3b6 0o RO# <br /> 3500 Z�� <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC <br /> E H D 29-01 07/28/10 WELL PERMIT APP <br />