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,r <br /> j • • FILE COPY <br /> SAN JOAQUIN COUNTY <br /> rk <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone:(209)468-3147 Fax: (209) 468-3433 Web:www.siciov.oro/ehd UNIT IV <br /> �4G/FO. <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <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 offthe San Joaquin County Environmental Health Department. 5� <br /> Site Location 1 /l2 e Wr,.er-4nDross Street Lf,L�C�!-//,ftA-e City/Stat l - Zip '?5_2/V APN <br /> Property ?g? Z—e'e_ 4 a�. <br /> Owner Address // Cit y/State Zip Phone <br /> C-57 Contractor Address/k-5' •//__ /� City/StateLic hone9� = —653 <br /> ConsultantlSub Cntr� Address aZ c 7"c ZSZ7 City/Stata Lic Phone2l���r� <br /> Billable Party klA.v &,ede! Address .Z A� Sl e- ZS-d City/State- —Zipy2 Phon'29 ? - <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WE,6WBORING(CPT,GEOPRWE,HY,r,7ROPUNCH,HAND-AUGER,OTHER) <br /> OIL BORING os _ <br /> ❑WELL IDs <br /> ❑OTHER Os <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> X0 <br /> —[I [I HOLLOW STEM DIA.OF BOREHOLEr2� ❑MULTIPLE CASINGS[IMULTI-LEVELWELL CASING DIA: <br /> —0 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS /101 <br /> p TYPE OF CASING: O STEEL C PVC ❑ OTHER <br /> _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL S_q/ TREMIE TYPE TO BE USED: O AUGERS ❑HOSE ❑PIPE <br /> SOIL BORING WUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes'pi(1Jo(MAXIMUM FREE FALL 2EPTH IS 30 FT) <br /> _0 INJECTION('e.Nr Soarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Q cep <br /> _[]OTHER: ❑OTHER: APPROX.BORING DEPTH <br /> ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑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 /> #OF WELL(S)TO BE DESTROYED C]OVER-BOREDIAMETER OF INCHES TO DEPTH OF FT <br /> W—ELL 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 /> Regulations,and all applele a rnia I ws. <br /> Signed ��7�/ / Title/Company <br /> Ile <br /> tiy„ • CJ'✓�[�1�ST e�/�� �� <br /> Print Name �- / PS _ Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 14 (Q C. ff drn,r 4/77uE <br /> WORK PLAN DATED 141'R11- 13 <br /> APPLICATION ACCEPTED BY -.(- 110 gKu M DATE ED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION B) ATE 6 <br /> DESTRUCTION INSPECTION BY DATE <br /> COM M E NTSICONDITIO N S: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST I PR# <br /> 2t0 5 $ 125X 1 1382 QCCCA4112-13 sR# 95 <br /> p RO# <br /> �, lV� 37s 3509 <br /> PR# <br /> 2900) <br /> C-57 {' WC ✓ WAIVER N� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT JLENCROACHMENT DOC _ <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />