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I t2��� 1 <br /> SAN .JOAQUIN COUNTY <br /> LOP <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> ..: -..;P. Telephone:(209) 468-3454 Fax:(209) 468-3433 Web:www.siciov.orglehd <br /> WELL & BORING PERMIT APPLICATION °Lr��l <br /> pg <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMED �Jls� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Aj(I^ <br /> C . 9 L UWtth S <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appilcati Eh yjR,�ompliance an <br /> Joaquin County Development Tiit�lle,Chapter 9-1115.3,and the Standards of the San Joaquin Courntyy Environmental Health De p'hktnl�VTI,f t1v <br /> Site Location��n�.TM f a Cross Street J.Ak Ewa re '•f- city 1"Wvr► Zip <br /> Properzip SVJ14 � Address ISS700 !�iG I< C���Zip Cl s3�n PhoneZo�.-loS1_�OI R(D <br /> C-57 Contractor ><h Ila 4 1 n�. Address City �_Li c Phone S�lGj <br /> Consultsnt/Sub Cntr Address `}A� 5AMC k;O_T Lic Phone R4j43-- <br /> Billable Party_ Address City Zip Phone <br /> GIS Coordinates:X Y <br /> CqN&TRUCTION WORK TO BE PERFORMED: <br /> NEW WELUWMING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> (SOIL BORING IDs -new►— 4;.�Tj7-,��� <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE_�/ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMERJDRIVEN 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 /> DIIII SOIL BORING 4 X PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ❑INJECTION I..e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑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 /> DESYRUCMOM TO 19E 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(?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 pplication and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,an all applicabaHornla la <br /> SignTitle/Company <br /> Print Name / i n.w i1 Z� �a�NS� ' P�e S A Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS D S-/11�"ti S� t4tiJ IF&Ac IR SU <br /> WORK PLAN DATED 30 D <br /> APPLICATION ACCEPTED B9 DATE ISSUED ARE 9 <br /> GROUT INSPECTION BY 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# INVOICE <br /> REQUEST PR# <br /> �9bS� $122x t3 �8 /d�, 3�bG SR#00 0950 <br /> RO# <br /> 3500 <br /> ,2q-So 3(010- <br /> —3'1106 X350 � l7, io isao <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 WELL PERMIT APP <br />