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PguOy. SAN JOAQUIN COUNTY <br /> LOP <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION <br /> i { <br /> - '. 600 East Main Street, Stockton, CA 95202-3029 1— <br /> Telephone: <br /> Telephone: (209) 468=3454 Fax: (209) 468-3433 Web:www.sigov.oralehd <br /> WELL & BORING PERMIT APPLICATION UV2010 t <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION j <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDI .�Eftljr ;fpp�1r <br /> Application is hereby made to San Joaquin County fora permit to construct and/or install the work described. This application is made�rd�ce with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health'Department. I <br /> Site Location S C? Lt Cross Street r C City Zip APN Z33"0���Q+ <br /> Property Rd <br /> Owner Address �� W )�- City 'i y Zip Phone � <br /> C-57 Contractor Address City . Lic Phone <br /> ConsultantlSubCntr _ Address 1� Ity ;� �_ Lic Phone <br /> Billable Party kleiln��.(r�o t� Address } ICJtY Zip Phone Z[ '��F�- <br /> GIS Coordinates:X OF41Y;2-QQ!g;jO 7 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> gNEW WELLIBORING(CPT,91FOPROSE,HYDROPUNCH,HANb-AUGER,OTHER) <br /> SOIL BORING IDs Ll- 7 -1_ Rey = yam=� <br /> ❑WELL iDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _0 MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS[I MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTIONVapor/Water ❑HAMMER/DRIVEN 'CASING THICKNESS TYPE OF CASING: ❑STEEL ElPVC ElOTHER <br /> ❑ <br /> ❑SOIL VAPOR PROBE MUD ROTARY DEPTH OF GROUT SEAL : TREMIE TYPE TO BE USED: ❑AUGERS ElHOSE C]PIPE <br /> SOIL BORING ❑PUSH POINT(GP!CPT) GROUT SEAL PUMPED:❑Yes Ll No(MAX{MUM FREE F LL DEPTH IS 30 FT) <br /> _❑INJECTION(i a Air Sparge.Ozone)€24 HAND AUGER GROUT SPECIFICATIONSe(q � <br /> —[I OTHER ❑�O7HER: APPROX.BORING DEPTH El BOLTED TRAFFIC BOX OR E]STOVE PIPE <br /> CONDUCTOR CASINGM 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 /> # <br /> OF WELL(S)TO BE DESTROYED [_1 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( 3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION'APPOINTMENTS <br /> r I hereby certify hat I have prepar this app n and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulat€ons,a II applica Ee Ca arnia laws. <br /> Signed �2_ Title/Company <br /> Print Name T I r/� [ l _Date <br /> DEPARTMENT USE.ONLY <br /> SITE MAP IN UNIT IV FILEISITf ADDRESS &A ` <br /> WORK PLAN DATED « w <br /> APPLICATION ACCEPTED BY 11DATE I SUED II y v AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY ,V DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: 57' <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# <br /> PE CODES FEE INFO AMT REMITTED CHECK'# RECV'D BY DATE INVOICE <br /> REQUEST/SPR# <br /> SeS <br /> $ 122. !. 7LZ s 1 b 0 3 �- \�� fb SR# 61 } Z.�d <br /> tG LP 3500 <br /> PR# <br /> 2900 <br /> I 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 /> t <br />