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• � � FILE COPY <br /> 0 SAN JOAQUIN COUNTY <br /> a ' ENVIRONMENTAL HEALTH DEPARTMENT <br /> Q: �1 ¢y <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 I T�QN <br /> / UNIT IV <br /> �• -� -;;:P Telephone:(209) 468.3147 Fax: (209) 468-3433 Web:vvuvwsig,�v.ora�ehdn�Q�_ ) — <br /> �iFO$ <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND R€Mk"®fdWEE'NTALH LTFB <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 �4{20(� Cross Street w•,Y Lt,1 1 VrA City/State'TM%, zip9 (� APN 2�7.4M- 0-i <br /> Property L n�� <br /> Owner ►--1(IV L,f(IVB I?w_, Address Z {�ty1�(ytt,._Kfy�. City/State Zip9 S�Phone <br /> C-57 Contractor �'1� Address �U �'l1\� City/Slate is D Phone9jt9-(j&? <br /> Consultant/Su Cntr 0 - dress ID9IFr7 7k,&L CAAj k City/State Lic?�hone q16- 'ft-$r'LL�' <br /> Billable Party,....1PU'e.,h,C Addressit <br /> ffi <br /> Shin d Piro s— City/State ,e- , Zip <br /> GIs Coordinates:X Y -e-1 I <br /> 3tM•.. <br /> _ 7 37y�— z <br /> CONSTRUCTION WORK TO BE_PERFORMED: <br /> EW WEOR <br /> LL/BING(CPT C--Wtl4�AF PYDRnaI INCH,HA� 4[JGEP OTHER) <br /> 'OIL BORING IDs <br /> 'mss ELL IDS. dp, 1 �— <br /> 'LJ OTHER IDs <br /> TYPE&#OF WELLMORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 3L?'<[�ONITORING DLLOW STEM DIA.OF BOREHOLE _t''Lu _ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS 40 TYPE OF CASING: M STEEL $(PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE [I MUD ROTARY DEPTH OF GROUT SEAL Zgl( TREMIE TYPE TO BE USED'I7 'AUGERS El HOSE ❑PIPE <br /> ,SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED: ❑Yes 4NO(MAXIMUM FREE FALL DEPTH ISS30 FT) <br /> _❑ INJECTION(I.Al Soame Ozone)❑HAND AUGER GROUT SPECIFICATIONS_ <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH_�� ❑BOLTED TRAFFIC BOX OR %STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth:_ Boring Oia: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD(CHECK ALL THAT APPLY) <br /> #OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑ PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin County Ordinances, Rules and <br /> Regulatio n �el1a b California laws. c <br /> Signed \ Title/Company <br /> Print Name _VAd% lA�nY\C Date_ <br /> V DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS S 6I9w<,cN Roo) kfik-e{J <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY .I DATE l$iSWUCIF <br /> EA �Gqy <br /> GROUT INSPECTION BY FINAL INSPECTION BY <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 /> �1qQ .,4 REQUEST PR# <br /> ✓` IU� $ 125x I U7 C.6(Anif?eQ S—SJ'/�` SR# Vq <br /> z903 375 RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-5729-01 5/G9/t2 WC ��WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC <br /> EHDWELL PERMIT APP <br />