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SAN JOAQUIN COUNTY 4 ,6LF I L E COPY <br /> //'oA <br /> N ?� ENVIRONMENTAL HEALTH DEPARTMENTO (NLOP <br /> 600 East Main Street, Stockton, CA 95202-3029I UNIT UNITGVTION <br /> �4o Telephone:(209) 468-3454 Fax:(209) 468-3433 Web:wwn� <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 p�v.eI nt Title,Cha ter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. �y3_!'76C/�I I <br /> /Gj ,�.n'6gD¢r(1oa/ h II p(�'� ''"-UU <br /> Site Location �qrn - Cross Street Lor')14'JF. City Ldi Z 1 p fYG AP�-� <br /> Prope rt <br /> OwnerwMAddress ad l InI.Y nr_ City Zip ND Phone 333 6}00 <br /> C-57 Contractor Addresses C ��1C,ily t7r�„'�.Ic�Lic Phone(S��.SUI� <br /> ConsultantlSub22C��ntr Address aY1CL 'lL.gi,ity u�en,,a,av, Lic Phon�9a5)'�6•cZlioD <br /> Billable Party lM'LAy er,�5 Address h OCa,,;„ & ilyc✓anlCn,+++h Zip YYSB� Phone(q.;ts? /2(-�6G2') <br /> GIS Coordinates:X iX 4R�10.$S'� Y L"Cl-h6-I0.64 <br /> CONSTRUCTION WORK TO BE PERFORMED: - <br /> RfNEW WELLIBORING(CPT�EQP' �,HYDROPf�NCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs \�/ Va�u4.ltl�-j <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> i <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor)Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL ❑PVC C OTHER <br /> _0 SOIL VAPOR PROBE 0MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE _ <br /> �p�'SOIL BORING 1Oy-PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIUM FREE FALLAEPTH IS 30 FT) —L <br /> _O INJECTION(ie.Air$Dame.Ozon, [I HAND AUGER GROUT SPECIFICATIONS— AIS, M�ITS Z <br /> _❑OTHER: 0 OTHER: APPROX.BORING DEPTH S� ❑BOLTED TRAFFIC BOX OR 0 STOVE PIPE - <br /> CONDUCTOR CASING 0 No❑Yes:Casing Dia: Casing Depth: Boring Dia:= S.S <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS Z <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) to <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT �I <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:❑A GERM S ❑HSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE r^ <br /> COMMENTS IVrwt- O-.mJ.i.1 -rG1I`._o )/ r <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS _Dp <br /> 1 hereby certify that Pave pr qf C ared thi application and that the work will be done in accordance with San Joaquin County Oroina es,Rules and <br /> Regulations,and a pplica / if rnla Laws. D I 1 <br /> Signed / TiflelCompany RU I J I (JIYt <br /> Print Name eE A E, Alxh'r Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS IN IJ , <br /> WORK PLAN DATED Zp Z <br /> APPLICATION ACCEPTED BY .-(.`{o HKuw( DATE IS R. <br /> GROUT INSPECTION BY F 09 FINAL INSPECTION BY (l-G-/`L <br /> DESTRUCTION INSPECTION BY _ DATE 9h6'('Z-- <br /> 41 U <br /> COMMENTS/CONDITIONS' d <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> G REQUEST FIR# <br /> $125. / X0307 C°u� 5 y I� SR# <br /> 503 37) T 3�5,«p2 s o0 <br /> PR# <br /> 575 (2900) <br /> C-57 d WC d WAIVER_/yl C57 LETTER OF AUTHORIZATION TO SIGN PERMIT LENCROACHMENT DOCS <br />