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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> �N. •� 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> d T� Telephone: (209) 468-3454 Fax: (209) 468-3433 Web.wmN.sigov.oralehd <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 of the San Joaquin County Environmental Health Department, <br /> Site location 53 0 0 W,91f&j,Sf_ Cross Street City {Td Zip9 5 2zb APN Z-0- ;Z n7 <br /> Property ,r� p <br /> Owner I A64 CUd( //P�ro •r�c� Address 860 6 �•/2�S•�:�fE �/.� city�_Zip q 530Y Phone? <br /> Qq. <br /> C-57 Contractor Q�Cjj(.;tS Address lob 7 /"ln jQ S/ City Z4�Vr HOK Lir 716DTO Phone!ZL; o <br /> Consultant/SubCntr Address <br /> City Lic Phone <br /> Phone <br /> city Address2Rn y 0Billable Party iencoh rwg Zip/ 7 QD <br /> GIS Coordinates X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GE9f ROBE,HYO OPUNCH,,PANO-AUGER,OTHER) <br /> Z" <br /> ❑SOIL BORING IDs _ '2�) f5 •� (Ja•�', <br /> ❑WELL IDs Tr <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE V❑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' ❑AUGERS ❑HOSE ❑PIPE <br /> I�Ig SOIL BORING C1PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes C3No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e Air Sparse.Cmne1❑HAND AUGER GROUT SPECIFICATIONSft��' reafL 6ki <br /> _O OTHER ❑OTHER. APPROX BORING DEPTH 5 T t ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> / OMD CTOR CA ING❑Mo❑Vas Ca inp qia: Casing Depth Boring Dia. <br /> COMMENTS.��f� f 5t7,/ SGL/uaJ/f/jpJ /�uJ 6 � T�<z 2; <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:?CHECK ALL THATAPPLYI <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 /> TRENIIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑NIUSHROOM 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 prepar d is plication and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicab a at r s. <br /> Signed Title/Company <br /> Print Named Dates/ <br /> Lpc DEPARTMENT USE ONLY ! <br /> SITE MAP IN UNIT IV FILE-SITE A DRESS LLPP. <br /> AJj1� S Jr-- V V` /t it <br /> WORK PLAN DATED 131 1 j <br /> APPLICATION ACCEPTED BY DATE ISSUED O AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY. AID# FAC# <br /> PE CODES I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO f INVOICE <br /> REQUEST PIR At <br /> SR# �� lv <br /> Ro <br /> 9500 <br /> PR# <br /> (2900) <br /> C-57_j'ef_ viC tTi.AIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERNIIT ENCROACHNtENT DOC <br /> EHD2S-;t 7-_3;tp P:ELLaERtllTA?P <br />