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y <br /> 1 <br /> Oc t. 18. 2012 3:54PM No, 1456 P. 3 <br /> i c � <br /> t <br /> g. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> ' 1868 Hazelton Avenue, Stockton, CA 95205-6232 817 TION <br /> UNIT IV <br /> 34 <br /> Telephone:(209)468-3147 Fax:(209)468- 33 Web:w".s7aov.ora/ehd UNIT v <br /> WELL & BORING PERMIT APPLICATION STfK<- S <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> M 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. n <br /> Site Location 1% Sba �(ZUQ�7 '1 Cross Street �'i �- t$ PCV c City/Stale Zip Sj b AFN Kt' GV <br /> Proper G? <br /> Owne. •_D. L. Address 3_f� 5!W� City/stat __.,dip Phor �`� �3 <br /> C-67Contractor Address City/5tate1a1y� 2 La ' �� Phone q 3�3 S �0 tibwe.C <br /> Consultent/3ub Cntr(Il a h'tL, Address'76I LWY►iV?A"1!j AV? City/State�(dC !Ix Phone <br /> Billable Partyvas llivC�.i'Use Address I ko 600AA" Cily/State .OlM p RSt& Phone 411 <br /> GIS Coordinates:X Y <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&d OF WELWBORING INSTALLATION TYPE CONSTRUCTION SPECIRCATIONA <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMERiDRNEN CASING THICKNESS TYPE OF CASING: O STEEL ❑PVC D OTHER <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO 13E USED. ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOII BORING ❑PUSH PRINT(GP/CPT) GROUT SEAL PUMPED:❑Yee ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> -0 INJECTION ff.e.nlr8p as Orme)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No El 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:tCHECKALL THAT APPLY) � <br /> . CL#OF (S)T BE DFSYRO ED OVER BORE DIAMETER OF INCHES TO DEPTH�OF <br /> WELL 1178; .k e-;g �iLI01L ff CS 4i� RESSURE 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(a_3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby that have pre this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Ragulatlo al a pill ble mia laws. <br /> Slaned Tllle/Company \T7�T7 ��O�b��� } 11 w•D�yL�4 I <br /> Print N `' Date ko °B t <br /> /DEA MET VSE ONLY / <br /> SITE MAP IN UNIT IV FILE,SITE ADDRESS <br /> WORK PLAN DATED Z Loll •r � s -.t .J�_ <br /> APPLICATION ACCEPTED BY DATE l 711 <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY_ DATE F-9 13 <br /> COM MENTMONDITIONS: . <br /> ACCOUNTING ONLY: AID;« FAC# <br /> PE CODES FEE INFO AMT REMOM13 CHECK# RECV'D 13Y DATE SERVICE RO 0 INVOICE <br /> REQUEST PR 0 <br /> 3SDZS 125x la (Z�d (�653�' �.�-,r✓ !b ZL �Ls 6GSYS! <br /> 3So 3 3�S 375' '' 4 4 °D o�6 <br /> PR# <br /> 42900) <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> END 2"1 5109/12 WELL PERMIT APP <br />