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J , <br /> $ �q 4uttr. SAN JOA UIN COUNTY -- <br /> LOP <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> c�!1roYi. s <br /> Telephone:(209)465-3454 Fax:(209)465-3433 Web:Www.slcjoy.orcltehd . <br /> WELL & BORING PERMIT APPLICATIONx, x' <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIONI <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I NVISONMEN �EAtTi1 <br /> Application is hereby made to San Joaquin County for a permit to construct andfor install the work described. This application is made Int1$ Q ' tt, ,ri <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site location s Brei t titjrly' Crass Street City I-,,, Zip '^. APN <br /> Property <br /> Owner r r�^c 1Cir rrs t+r -Address fi`i `+ je�r. Ctty It t Zip� ` Phone Z ' <br /> C-57 Contractor t ' ,i{c=< Adores Id Clty W d.VAIttA J /LIC` ki cC_Phone�t�MGGI <br /> gg����qq)� ►�g� #4rir an a. ey MO 4-ftw. :�1�G"Lic Phone : a7 P?9-.2-00,q <br /> Consuitant/5ul�lN'tr ! �✓tr5r5 Address City �ydrti <br /> Billable Party" 6 rr-"-j *ate�V, �,Address t' i'w(5, ' 1 City kVdt ZIpgfj2'-L0 Phone,0` b 7 za's-S <br /> GIS Coordinates:X-- I'!L '"!._Y _,� <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> t'. NEW WELLlBOR1NG{CPT,GEOPROBE,HYDROPUNCH,HAND-A�R,OTHER) � �f,�,,tt�,� �.f rr-r� <br /> �)WELL IQs <br /> I�OTHER iDs <br /> TYPE&#OF WELLlBORiNG INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> „❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE O MULTIPLE CASINGS DMULTI-LEVEL WELL CASING DIA: <br /> ��EXTRACTION:Vapor/water O HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL❑PVC ❑ OTHER <br /> ._[t SOIL VAPOR PROBE [I MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED; Ci AUGERS Q HOSE ©PIPE <br /> ' ®SOIL BORING PUSH POINT(GP/CPT) GROUT SEAL PUMPED:[I Yes D No(MAXIMUM PREF FALL DEPTH IS 34 FT) <br /> ,p INJECTION 8 a&r_S12raa Ozor,el❑HAND AUGER GROUT SPECIFICATIONS <br /> _O OTHER: _ ❑OTHER:_APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Oia: <br /> Ct3MMHNT$:f pct hr .t' ,t, y Y tt( I C' klkY[T i� �t* 7ti i Y ^�"sg" t <br /> t t C t ttt#I' <br /> ' <br /> NOTE: OFFSITE WE!-LS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROAC14MENT PERMi3 <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD'tCHECK ALL THATAPPLYI <br /> r OF WEtl(S�TO BE DESTROYED I]OVER-BORE DIAMETER OF INCHES TO DEPTH OP FT <br /> WELL IDs: El 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 [I PIPE [I MUSHROOM CAP AT L3 FT) <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION AP OINTMENTS <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 /> R guletiqns,and ail applicable California laws. <br /> fIUelCompanyr+ Uz <br /> lortsr�t��_7 v�esls ?rt ,�r-rr <br /> Print N1 <br /> 4ul^ia2 C'nc Datev �- <br /> e <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS o t v <br /> c <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE ISSUED •� AREA ,S�r <br /> GROUT INSPECTION BY FiNAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE — <br /> COMMENTSICONDITI ONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> 5ERVICE RO#t INVOICE <br /> PE COODESt� FEE)NFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# <br /> l t $125. Iia` t'I t1 <br /> RO# <br /> 3500 <br /> -- PR# <br /> 2900 t7 le 5 6 <br /> C 57_ WC WAIVER_.-._ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _.... ENCROACHMENT DOC <br /> WELL PERMIT APP <br /> EHD 29-01 07/28110 <br />