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0 SAN JOAQUIN COUNTY 0 FILE C0PY <br /> r .yj ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 TdGA; <br /> Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.sigov.org/e <br /> A�rFOF� <br /> WELL & BORING PERMIT APPLICATION MAY 2 7 2014 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described. This application is mac1?f RW'FjSERVNMn <br /> Joaquin County TM- r`Hantgr 9-1115.3,and the d aro o�San Joaquin County Environmental Health Department. <br /> a4sso s.rlgNSf t�� He _ <br /> Site Location (�"A" K.'CA Cross Street V 5�t�;� kp 4a 1 City/State �c 4AZip APN 2t3f-022.01 <br /> Property P io]es;S S., r�., /ice <br /> Owner 1 Address Fier0 84Onc City/State Zip 7YIII Phone <br /> PAddress t^ 4 I-" — <br /> C-57 Contractor Sscc r• Teti L g $�r e City/State Lie9 //o Phone 4/6-90 3-77.0 <br /> Consultant/Sub rJtr Ad ress City/State `tea. rLic Phone 9/6 "S�`I-8`!yJ <br /> K/F 4. a. n sC3 _ ee SOnO• CN <br /> Billable Party LLC o! r dress 11 LIVT�.e rs?h 01"K. City/State `•� Zip 9�5'�'76 Phone-7o7_y,3T--tffi-o <br /> GIS Coordinates:X 3-7. 7-�G 2- Y _f 24,51`2 Z S V <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _O EXTRACTION:Vapor/Water 0 HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> _O SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> _0 SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _D INJECTION(i.e.Alr Soarne.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: ❑OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING[INo 0 Yes: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 PESTROYED OVER-BORE DIAMETER OF CF HES TO DEPTH OF So FT <br /> WELL IDs: ht t,r-1 -JKPRESSURE GROUT TO DEPTH OF Q FT BELOW SURFACE <br /> GROUT SPECIFICATIONS-f o ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE U$$ED:❑AUGERS ❑ HOSE �] PIPE / MUSHROOM CAP,4T(>3 FT) FT ELOW SURFACE <br /> COMMENTS,0^ N r..-✓S �•U�r .�r•rlle�crij' I/-4i LV'/ 4.: (i0.4� alk- c <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,piff all applicable ifornia laws. <br /> Signed Title/Company` GLl o ,SP �� e5MF4 r�J..cr3 vL-/ &rau <br /> Print Name Date-,C-Z-3 <br /> / DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS _ h6oy SE?J town Nr o S ATE )Cjt 1 7'2r+(2y <br /> WORK PLAN DATED M /I 20141 <br /> APPLICATION ACCEPTED BY -J- tlo fY/Cur"1 DATA90PARP, -G CL <br /> GROUT INSPECTION BY FINAL INSPECTION BY nLm(jQ 'A' ro' <br /> rc <br /> DATE G' <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CON DITI ONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> a ® $125X 37C)oZo (2ovrt/6j�_ 5'-Z IC/ SR# 3 <br /> 20ty 37S RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57_� WC t/ WAIVERyt�✓a C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT 1, ENCROACHMENT DOC �(/!g <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />