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PaU'N G SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> • 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> egr,Fo •Q Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.si ov.or <br /> WELL & BORING PERMIT APPLICATION 0 2011 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIA <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 VI��O�iNMMPPE7 TC an <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Depart en . <br /> Site Location Z?v4 f;Fru. .4 S}- Cross Street _SG,J,,- 4VQ City Px k4v'l Zip 75�Z0 APN 143-43 <br /> Property _ ll <br /> Owner /t'Is. ��� StiiCl�r Address ZK4 k `"+ati'f 5t'. City Zip Phone X-o"` q4-oz.33 <br /> C-57 Contractor c? :-&-j'j"44 Address X365 L 4-ii'AWn by, City '2ark+z?1.o Lic 6'363Y�- Phone' 465 IX <br /> Cons ultant/S ub Cntr 4r4f cis• •I Address City /-lactei4v Lic Phone Z.ari-S492,4? <br /> Billable Party Address City Zip Phone <br /> GIS 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 lDs Vt-I- ,UPi 2-, - <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 11 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ��� <br /> _❑EXTRACTION:Vaporl Water ❑HAMMERIDRVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC X OTHER <br /> /I—b(SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL ;.C 1 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 /> _.._.I1 INJECTION(i.e.Air Soarae.Ozonel❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING)<No[IYes: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 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 ❑MUSHROOM CAP AT(n3 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 licable California laws. (� /� / _ /� <br /> Signed Title/Company. �r -��F 6?0(n<1S_}J /�'T�cA 'I.Ij <br /> deef <br /> Print Name —_- w, Kvvrd�r� Date 1-10-11 <br /> DEPARTMENT <br /> -1p-11DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS ZSsOLf 4-- <br /> WORK PIAN DATED 17 t 2- I e <br /> APPLICATION ACCEPTED BY DATE ISSUED it 1! 0 AREA <br /> GROUT INSPECTION BY e___ FINAL INSPECTION BY DATE <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 /> p5 <br /> $122- o&IA11,t SR# 6(T5� <br /> 3503RO# <br /> 3500 7-01 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC <br /> FHn qa-m 0712Alln 1— .,moo..T— <br />