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� r �k V P ,!fya"I" SAN JOAQUIN COUNTY co -�� ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 SI TLA: < FTelephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.siaov.org/eh 1 71TiVti 9c; oa� OCT � � l�j� WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIN iiillli ��;`a; +'^ NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .._' �'�qL7-H vlfr F-* ft 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 wllh 'IT-S Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the an Jopquin County Environmental Health Department. Site Location I ! Iti , (� S Cross Street(-Or�� ((r)UJCity Zip �S�� APN 7 Property n _ ''� 11 �r� Owner nt'S��p.m Address 5T W. I I City V,; t Zip Phon �5 >S' �Cf� C-57 Contractor F Von Lt ��l1lf Address 3-7 City 5 6 n Li � Phone(._ 00)00 7vU Consultant/Sub Cntr Wz o 6eO, Address (b 77pp bk/ �G. City Y'1 Lic " i� Phone l.O �('y3G'U Billable Party ^vin rt' Address QD t iy ?-.)'q `'� City (,kj Lc( Zip 7 5-7, Phonej)6-11 'M � GIS Coordinates:X Y CO STRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDRO NCH,HAND-AUGER,OTHER) Q(SOIL BORING IDs I _ 7t I ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE �t,J MULTIPLE CASINGS EIMULTI-LEVELWELL CASING DIA I� _❑EXTRACTION:Vapor/Water C]HAMMER/DRIVEN CASING THICKNESS � "� TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEALCn , — TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE —A SOIL BORING PUSH POINT(GP/CPT) GROUT SEAL PUMPED:ElYes T2rNo(MAXIMUM FPjEE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Sparse.Ozone)El HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH /G' , ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes: Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 1 hereby certify that I have piepared this ap •cation and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all applicogleCalifornia I Signed Title/Company Print Name B ril Y) P I M C'7 Date DEPARTMENT USE ONLY FILE COPY SITE MAP IN UNIT IV FILE-S TE ADDRESS�}SS W f'iCP i 1P-r..7 541.4�,l I Tina . WORK PLAN DATED d1,5 1111 APPLICATION ACCEPTED BY � j��^ DATE ISSUED 10/7—t ! AREA GROUT INSPECTION BY C", lt'1 I I/ FINAL INSPECTION BY �t_r�— DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# aot�s $ 122" IZs SR# b3�yb ado3 47 tom Rsoo X45 p � 335._ iso C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP