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SAN JOAQUIN COUNTY <br /> �.•Ems' LOP <br /> ENVIRONMENTALENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION <br /> N < <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> P Telephone: (209)468-3454 Fax: (209) 468-3433 Web:www.s' ov.or leh <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATI11 IONS 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 tlescribed. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the of the San Joaquin County Environmental Health rDepartment. ��f 4- <br /> $R�ww) Olvc_'CrossStreet mnlow ��� - City 70 7� Zip r 1CfYKl _5i+7Eytltlt- - <br /> Site LocatioW n <br /> Property ( A�74 "t C(, �TcYX- Zip `k - <br /> P tS a• �� � City �� Phare <br /> Owner � 'Address , _� C1 <br /> Address �Ze 1r�- 1L� City !,I3 0 t7eDW ALic ID Phone I�.1D�g.��11`nn( 11ccs� <br /> C-57 Contractor D� � I Phone gi(P•RP5 <br /> PAi)� Address �� lalL �- City�!F)`7U1Y1 _Lic <br /> ! Consultant/Sub Cntr It t25 City Cit pR s 6 30 Phone r r <br /> I I Zi <br /> Billable Party 1 a� Address <br /> Y It <br /> GIS Coordinates:X I <br /> t <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) j j <br /> I ❑SOIL BORING IDs <br /> i ❑WELL IDs i <br /> [I OTHER IDs ,� <br /> TYPE&#OF WEWBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS a <br /> _E1 MONITORING El HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS I TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 4 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> `_❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ❑INJECTION Q a air sRarge,Ozone ❑HAND AUGER GROUT SPECIFICATIONS i� <br /> ❑OTHER ElOTHI R: APPROX.BORING DEPTH I� [I BOLTED TRAFFIC BOX OR El STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: 1� � <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY 0*4 <br /> OF WELL(S)TO BE DESTROYE-D1 i �y OVER-BORE DIAMETER OF INCHES TO DEPTH OF _FT PV4- <br /> #W LL IDs: - M V -! V 13 �y PRESSURE GROUT TO DEPTH OF O FT BELOW SURFACE�rA GROUT SPECIFICATIONS ne 132 rtW t- ❑EXPLOSIVES FROM TO FT BELOW SURFACE r n '�) <br /> TREMIE TYPE TO BE USED: AUGERS ❑HOSE PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS MW'l `6 31 <br /> 3 <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS b� _ <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California laws. <br /> Signed -4Title/Company <br /> Print Name U N Date <br /> DEPARTMENT USE ONLY <br /> T <br /> SITE MAP 1N UNIT IV FILE-SITE ADDRESS Y + <br /> WORK PLAN DATED II <br /> APPLICATION ACCEPTED BY i{ DATE ISSUED IZ AREA <br /> GROUT INSPECTION BY A FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE I� , <br /> COMMENTSICONDITIONS: <br /> 'r <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 /> 35-0 z $12c. SR# �q {cj1 <br /> RO# <br /> 3?5• / ii 35Da O 3 ! <br /> PR# <br /> i� 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 0712811 D WELL PERMIT APP <br /> I'h i <br />