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FRIEGEIVED <br /> f a 0 R I G I i V !"'► LAN JOAQUIN COUNTY 06 2011 <br /> �? I ENVIRONMENTAL HEALTH DEPARTMENT L p <br /> ,Mtl�HN <br /> 600 EE 'ain Street, Stockton, CA 95202-3029 ENVIPE M T <br /> \\\4tfk`gN•" Telephone:(209) 46L .i4 Fax: (209) 468-3433 Web:www.sioov.oro/ehd <br /> WELL & BORING PERMIT APF :ATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVES ,,3ATIONS AND REMEDIATION f <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 /> Sit(Location s, Cross Street /- Z05 City <br /> Property %/uc� Zip APN QG9-�fLe- 3! <br /> fi <br /> Owner 7(uL lny f6,, Ll !/1': <br /> ;Mr Address /V q City 6f :4; Zip-15 0 Tu Phone <br /> C-57 Contractor .+!/n Address _947o /-lOLac Ra City H...fwet Lie 4S SiC5 Phone 9t5-;+;-Syw <br /> Consultant/Sub Cntr Address /4Y'M lutvsic4 w. City 5", Lie_Phone ^76 7- F35 Y85,e <br /> Billable Party Address City Zip Phone <br /> GIS Coordinates:X V.7 ( Y —I z I•s/9 '�-3 <br /> CONSTRUCTION WORK TO BE PERFORMED: -C <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs O <br /> E)OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTIOI .:IFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE -Z� 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER _ _ <br /> 0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS ❑HOSE 0 PIPE <br /> --flil SOIL BORING 0@ PUSH POINT(GP/CPT) GROUT SEAL PUMPED. 0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT)_ p <br /> - <br /> _OINJECTION( Ai 5 ozone <br /> IO HAND AUGER GROUT SPECIFICATIONS i'!✓lYsna/ C/NylnY er /Jyd Ti N, <br /> 0 OTHER: _ 0 OTHER: APPROX.BORING DEPTH 10 ❑BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING❑No Cl Yes:Casing Dia: - Casing Depth:__ Boning Dia_ <br /> COMMENTS:_ <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS.-�REEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THATAPPLY) <br /> _#OF WELL(S)To BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF Fr <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 ❑PIPE ❑MUSHROOM CAP AT(_>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRe AFTER PEP"'T ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will, ane in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and���all�applicable California Laws. / <br /> Signed �lrF.Y T. �i' Title/Company e 4lrf / —144 <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS #A"&" RJ NoRr/F a 54fHa'4F <br /> WORK PLAN DATED (o-S--I( <br /> APPLICATION ACCEPTED BY J. `kipjtus,1 DATE ISSUE AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY rog� a <br /> DATE <br /> DESTRUCTION INSPECTIO Y DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING:FEE <br /> AID# FAC# <br /> PE CODES FO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> ppREQUESSTPR# <br /> ; (0 . SR#500 (3500) <br /> ;`•IU37S PR# <br /> 2900 <br /> C-57 WC WAIVER $A)a— C57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ ENCROACHMENT DOC UQ <br />