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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> ►� <br /> •'•� ��:�• 600 East Main Street, Stockton, CA 95202-3029 TE MITIGATION <br /> gid•., :;:.�;;P Telephone: I <br /> (209)468-3454 Fax: (209) 468-3433 Web:www.s RVF <br /> ov. <br /> �/F R <br /> WELL & BORING PERMIT APPLICATION 9 2012 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REME <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FF��( TT�� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicaTRS/1t �41�h'3an <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health De <br /> Site Location!I'6Y1 !1(Yl ross Street L 4) CitySp Zipj APN <br /> Property <br /> Owner uI CU Address { ly� /1 U Citywood <br /> b,: y ZiR 5L5.6 Phone V—J01-5 <br /> C57 Contractor Address Z lAiv< vik A City Lic ?+335`1 Phone <br /> Consultant/SubCnrS� �1 Address2330 �4vh(/t hII$550 City Lic`5bS? Phone 5�//7&n 71X+ Z <br /> Billable Party GIV/cn1L Address J730t9�� NA P"f 5t> City (4•�", L Zip c750?1 Phone 53} <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> [:]WELL IDs M w- W-14/15 <br /> ❑OTHER IDs ' <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ^ / p <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE o`I MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: ' <br /> _❑EXTRACTION:Vapor/Water HAMMER/DRIVEN CASING THICKNESS I`I a� Z(( (M'4U OF CASING- ❑STEEL PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL L/0"LILI REMIE TYPE TO BE USED 1%AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPEDYves, No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> 4­4 <br /> INJECTION(i a Air Sparge.ozone l[:]HAND AUGER GROUT SPECIFICATION '`^ (Lt'" )'J 14w')f, <br /> _❑OTHER C1 OTHER APPROX.BORING DEPTH W1�90,'-lZ) l , IBOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> n , lL Pl I A d 1 <br /> 1, If- 'ki <br /> I_ 'kI I CONDUCTOR CASING[I No❑Yes Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: CCS wd j1 �n U1L(( <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 ❑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 /> Regulations, d all applicable California laws. I <br /> Signed S(Af Title/Company �N1�� / Sari F&Iri.lMkOy, I'(' <br /> Print Name S �A"nw Date'3A3-I Z <br /> C� DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-S17E ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED DATE ISSUED 1— AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: bC'7Z�3 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> SR <br /> j - a�o� ( 2111� (300 3l s� ooS400 3g <br /> 4oz— <br /> PR# <br /> 2900 <br /> 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 />