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SAN JOAQUIN COUNTYILE C <br /> ENVIRONMENTAL HEALTH DEPARTMEN 0 LOP <br /> •' 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATIONUNIT IV <br /> �;• <br /> n.... Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.s' ov.or /ehd <br /> WELL & BORING PERMIT APPLICATION t > <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FES ZCf <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 DepartT'en' -`r.fL(`I rL HF--.AT <br /> Site Location 2egS 5, A4aC17rAwi' Cross Street Oc- rd Ur. City/State rac Zip 9S3 �6 p�P)+lil, it6-i/!hr_wZ <br /> � <br /> Property <br /> Owner Pt-lot%& 'fk#re jKe-r Address LZ9S 1k-1,-4r1hr.4✓!Jr City/State Zip'Y'Qz6 Phone s/yV' S <br /> C-57Contractor (J0/4j4ucc.; Or.6GW Address 0 O. (3oX 7Y/ City/State 4tiOoJ1aoJ Lic8f( 760 Phone 530 Z4f 2(,y/ <br /> Consultant/Sub Cntr %eA,-Peck Address T—YG% U/, City/State Zak-.#kg Lic Phone X11(0' 853—!,'00 <br /> Billable Party 1 e,f .--7r-Gc.Lt Address .Sop-At- City/State CO'4"ArZip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPRO HYDROPUNCH HAND-AUGER,OTHER) <br /> SOIL BORING IDs s(3'�7Cr(✓�/� (3� S a S a - <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE .3" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL/041H,.y REMIE TYPE TO BE USED: ❑AUGERS ❑HOSE NrPIPE <br /> (2_p SOIL BORING 5a PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes N[No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ❑INJECTION(LeAr Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 3 rt Zy+ 3dl SSI❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & 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 L3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I hav this ap 1' tion and that the work will be done in accordan ith San Joaquin County Ordinances, Rules and <br /> Regulations,and a li a allf aw <br /> Signed �/ - Title/Company C <br /> Print NameT /�/s �r�. u�� Da;e—A <br /> DEPARTMENT <br /> CUSE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS i (11 He &my u2 Dec VE <br /> WORK PLAN DATED cL 4 t <br /> APPLICATION ACCEPTED BY oJ3K.r ft't DATE l SUED REA_LLCL� <br /> GROUT INSPECTION BY FINAL INSPECTION BY ATE <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# INVOICE <br /> C REQUEST/ PR# <br /> I0 S $125x 1 /Cp /0 J�loZ ��(��(JTE2 ��-l3 SR# 61657 <br /> RO# <br /> �� 75 (3500) <br /> PR# <br /> (2900) <br /> C-57 WC WAIVER _ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC _ <br /> EHD 29-01 /09/12 WELL PERMIT APP <br />