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SAN JOAQUIN COUNTY <br /> LO P <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION <br /> Q <br /> .y <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> • ... ;P•. Telephone:(209) 468-3454 Fax: (209) 468-3433 Web:www-s' ov.o CE <br /> '9CfFORt, <br /> WELL & BORING PERMIT APPLICATION 1 ZOi1 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMED <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IRO MENTAL HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applica�� gVf��lth San <br /> Joaquin County Development Title,Ch�pter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Dep 13y�G-Uc"Z <br /> -7 <br /> 33�� ; gAar,t- (3 S-Y� QV C <br /> Location 40Si r�lL s~.lu Cross Street city �i�f I�T°'�' zip q��3 APN 1:;:7- <br /> Site NI-ocO�f <br /> OwnProper <br /> ' �y�euqv' 11M Owner t`de' Address y2S �- �fo 24170 317 Cityb '�' ZipFrzPhone <br /> ac C-57 Contractor of w ,Address City Lic Phone I a <br /> v M'+^ <br /> Consultant/SubCntrlrry�.,+W7 Ctp,.rF,.l�Address 1d�t(JLek1� t �K !Cj City ( F(o CiCy>��gic Z?Phone I�YYY <br /> Billable Party fir a.4w k ll> CJ►•r��l « Address 10SY0/Itl(7 A,05- 1?6 City �Y`tCf<b 64Aj hZilj Phone C(!(s �r{y ar23 387 <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 <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: <br /> ❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS ___ TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> (O-&SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _Z 0 SOIL BORING Ll 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(I a Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS p&,rT CeA6,,r,7 <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS 8r 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 ave prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations, c�a plica le California laws. <br /> Signed / Title/Company (O4-S t` 2 CL <br /> Print Name _ _ Date--Date--t7j cf. r <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILLE/ I <br /> -SITE ADDRESS? W' ^�'ti v'1 S I <br /> WORK PLAN DATED d11 1 a l�1 O - - <br /> APPLICATION ACCEPTED BY DATE ISSUED /1 AREA <br /> GROUT INSPECTION BY _ FINAL INSPECTION BY — DATE ? Z <br /> DESTRUCTION INSPECTION BY_ DATE <br /> COMM ENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# <br /> oZ (•US $122x I Z2-� /Y/VZZ (�� / a1 fl SR#606/�S� <br /> 29.03 3��� 34�" t'1 a7 �,� z4 /, Ro# N/� <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> WELL PERMIT APP <br /> EHD 29-01 07/28/10 <br />