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SAN JOAQUIN COUNTY <br /> DoE coy LOP <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION <br /> N'. j <br /> - '• 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.siclov.orq/ehd <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 0 C w VAross Street tALf`['`2 City S�G1�`0�Zip g f�✓1 APN Gf230[ <br /> Property /� <br /> Owner ! /�O ) Address Sid�! e. N a26 City r1��&fVV ZZip 9-Fi 1S Phoneme Q V6,"?-7 <br /> C-57 Contractor tGiS/Oh 4 �1�Qdress 2� 6(05 ��S Z044— City S_1UeV6A1c 63635TPhone209 ` 65--j712- <br /> Consultant/Sub Cntr Address City Lic Phone <br /> Billable Party Address City Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(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 ❑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.AirSoaroe.Ozone l❑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: <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: jZrjPRESSURE GROUT TO DEPTH OF g ! FT BELOW SURFACE <br /> GROUT SPECIFICATIONS EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ®PIPE ❑MUSHROOM CAP AT(>3 FT) 3 FT BELOW SURFACE <br /> COMMENTS <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,and 1 applicable California laws. <br /> Signed Title/Company a u?tn.-_2 <br /> Print Name 4 Date tq -it I <br /> DEPARTMENT USE ONLY <br /> c, <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS p <br /> WORK PLAN DATED 1113111 <br /> APPLICATION ACCEPTED BY DATE ISSUED l AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATER <br /> DESTRUCTION INSPECTION BY IA G 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 /> a �oz <br /> $129-, 3 3 11 SR# Ip3$t <br /> a-`ta 3 ov RO# <br /> 3500 <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 />