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"aRif <br /> y SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> rn < LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 ENVIROtI€ISL <br /> Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:www.sigov.org/eh�EF IM1T/4�IANS <br /> �fFORd <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND Rf�TjN Copy <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 /> 11 <br /> 137 1512-7 <br /> Site LocationVS 0, atr,%Sf Cross Street &(l-iSm ST City Zip APN <br /> Property- ,t ('" <br /> Owner n2?r-lY� SOS/ Address �T jt/ _, 6Cw ,, 5� City Zip �J�Phone ---!C 5TC3 <br /> C-57 Contractor Address?&(, dirk-C,teek_ 6/`. City Lic oZrJ9vy Phon WJ"�/moi <br /> Consultant/SubCntr {QIda r Address J,¢/rA iQr�pp City SfockIVA Lic Phone(.2�'y)9yd'-/3yS <br /> Billable Party Njuepoyi YVV, o,I Address 5123-/(I. />'C�C;ti �'t- City 5&C_X1441 Zip Phon�� -$ <br /> GIS Coordinates:X 37 26 Y—121, 30/ <br /> CONSTRUCTION WORK TOB RFORMED: <br /> NEW WELL/BORING(CPT OPROB HYDROPUNCH,HAND-AUGER,OTHER) <br /> JR�SOIL BORING IDs <br /> WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE) ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: X114 <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER 1A <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL It- TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING (PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes )(No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ❑INJECTION(i.e.AirSparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS dZ6cr O_iY!ieJC <br /> _VXOTHER:Ae_6g—I ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASINGXNo❑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 ❑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 (AFTE MIT IS ANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this applica ' nd that the do in accordance with San Joaquin County Ordinances,Rules and <br /> it <br /> Regulations,and all applicable California Laws. fr­:+�, , c, f / <br /> Signed Nbf rr Title/Company <br /> Print Name ' S Date_ Y/ <br /> J[ <br /> DEPARTMENT USE ONLY n6-& <br /> `J <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS 2 � //L'S V 1 AST, S7W� 2' C/�I 7 &7, <br /> WORK PLAN DATED 0,-28-1/ <br /> APPLICATION ACCEPTED BY J. yonru'r7 DAT YQ AREA �� <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE 1"4'/2 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> $125 x ( .( SR#d0�Y 108 <br /> p RO# <br /> (3500 <br /> PR# <br /> (2900) <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC /ll <br />