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FILE COP <br /> aDl SAN JOAQUIN COUNTY Y <br /> q: ENVIRONMENTAL HEALTH DEPARTMENT —LO P <br /> �. � <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> s%,::.�:T� Telephone:(209)468.3147 Fax:(209) 468-3433 Web:www.s ov.or /ehd UNIT IV <br /> JVi5 <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 The.Chapter 9.1115.3,and the Standards of the San Joaquin County Environmental Health Department. 9 <br /> Site LowtlonAve Chy/Stele( hn&L0PZtp45'330 APN11f-040-AW <br /> Property wfi"�al v r <br /> Owner J A'166 W &"T-ea1.�• NCAddress7ffd ✓S.(o� $ City/State n*ZipO 5'I'S7 Phone <br /> C•57Contractor PeA.����. Address7LOAI, fAv, ST Clry/Slala WeeaA✓PLicfG4f 72 Phone 5'10. 661•?Gcl� <br /> ConsultantlSub Cntr_ yl dpis Address 14tD AoC ,-1 A-1066 Citylslate��i4E Uc 6S-9-5- Phone IFl10• 3301 <br /> Billable Party '4Ae'4n,S Address 84l01lcL1cY)botn6 OS:O City/SlatGA.&C- &'4e Zip f-461 Phone 9/L. •52oL <br /> GIS Coordinates:X-ILl-2xrr48 v3a-. 8165'/0 <br /> CONSTRUCTION WORK TO BE PERFORMED, <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ROILBORINGIDs SB1f , -2, - 3. 'y , - S- -6 , , :;- -g <br /> WELL IDS <br /> OTHER IDS <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> —D MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE L'—ZS 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_ <br /> —0 EXTRACTION:Vapod Water 0 HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: O STEEL O PVC 0 OTHER <br /> _D SOIL VAPOR PROBE D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> 6—�SOIL BORING ()PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> INJECTION na.Alr scarps,onnet O HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: O OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING 0 No 0 Yes:Casing Oia: Casing Depth:_Boring Dia:_ <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:rcHECKALL THAT APPLY) <br /> _#OF WELLS)TO BE DESTROYED ❑O VER-BOREDIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: D PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS O EXPLOSIVES FROM TO F7 BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS D HOSE D PIPE D 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 prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all appll ble California laws. <br /> Signed Title/Company C-'e­ 3% <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS l el gil L %N <br /> l4RO Ia k,) <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY _(.�� n/.hKJ�7 DATE IS �(< <br /> GROUT INSPECTION BY FINAL INSPECTION BY 22-/3 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMEN TSICONDITION S: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECVD BY DATE SEP.VICE RO# INVOICE <br /> REQUEST PR# <br /> a4oS a125X / \ C'ou�7F �' -l� SR# dG77y <br /> i0 2 375 ssoa <br /> 2 <br /> PR# <br /> 2800 <br /> C-57 l, WC r/ WAIVER—kL'n- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT i/ ENCROACHMENTDOC &T <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />