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o P4U'ry. c <br /> SAN JOAQUIN COUNTY <br /> LOP <br /> al ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION <br /> t 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> Telephone (209)468-3454 Fax: (209) 468-3433 Web. www.sigov.org/ehd <br /> �rr:oa� <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS 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 described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards sof the San Joaquin County Environmental Health Department. <br /> Site Location R 51 Cross Street �� �/ City Zip � APN <br /> Property iy [ p /y <br /> Owner G-!I 47 T� �Y Address 33 1: r' Z rl City Zip PhoneW 9-Y31.6 <br /> C-57 Contractor Fleca-, lr Address City re Liq/A?) R Phone9ZS !-Tloo <br /> Consultant/Sub Cntr Address City Lie e� Phone <br /> Billable Party(geoco�t (Qv Address 6(a?1 SaC- City /QI K Zip9 Y77y Phone 2 37 -_5-500 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPRO�B HYDR I AJC i,H9{vq j�JGE3i OJ�fER) <br /> SOIL BORING IDs ��'1� IIGw� /'S y ['S (eFj <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z z ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION.Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING ❑STEEL ❑PVC ❑ OTHER <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED C1 AUGERS ❑HOSE ❑PIPE <br /> t SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑Nor AXIMUM FREE FALL DEPTH IS 3 FTQ ) <br /> _❑INJECTION ii.e Air Soaroe Ozone/❑HAND AUGER GROUT SPECIFICATIONS Ahgr <br /> _❑OTHER ❑OTHER: APPROX BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> /J COND T R CASIN ❑ o❑Yes ,Cas n Dia: asin,9 Oepth. Bon Dia <br /> COMMENTS: (4-al p-50 l SQxCO!/f24 V) (�v1 nT{7� �t/ <br /> NOTE: OFFSITE WELLS &BORINGS QUIRE ACCESS AG EEMENTS OR ENCROACHME T PERMITS Ste`` • <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:rCHECK 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 have pr pared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applica a rnia laws. <br /> Signed Title/Company A4,eOGd N <br /> Print Name / �C� � �'� Date U / <br /> DEPARTMENT USE ON�tLY, <br /> SITE MAP IN UNIT IV FILE-SITE ADR SS_ � S'I c�v"� yyl�lCC - <br /> WORK PLAN DATED I <br /> APPLICATION ACCEPTED BY 1-4 i-r01 L— DATE ISSUED 10hphlAREA <br /> GROUT INSPECTION BY j�_CO%.,-,- FINAL INSPECTION BY DATE <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 At INVOICE <br /> ' c _ REQUEST PR# <br /> oZ ci o5� 5 122 x 127.00 12�(Z SR# b?J� <br /> PL-`l v3 36L'CD o RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57_ WC WAIVER 0-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 0712800 <br /> `HELL PERMIT APP <br />