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I Z-`6`6 <br /> SAN JOAQUIN COUNTY <br /> �. �� •.o� LOP <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.orglehd <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIAtfa. •, � L <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �f/•^- f9 //�� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicatic . p EAV d pip compliance4 San <br /> I: <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health <br /> Site Location 2 � ���1`�� Cross Street �r t m:�1'L' f: City Iv w�Y� t 1Zip dP�` `� <br /> Property <br /> Owner for• h)j2 11;5jjjArj Address 11y700 a0 ►�t[_kt nl6(- ieeZips 53 7 n Phoneme<�—ro <br /> C-57 Contractor Address �n !ln %�nG 7 City � `( e Lic 7 Phone l9 <br /> Consultant/Sub Cntr Address ��,ni Arra, r1'..,G�,�,� 1?.1 S``+�ity k�s�� Lic Phone c;`^G� / <br /> �� -rr���:H1 <br /> Billable Party Address City Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ANEW WELL/BORING(CPT,QEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> QSOIL BORING IDs n e_— <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE J� ❑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 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> SOIL BORING 4 0 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 /> 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(>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 a plication and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,an all applicabl alifornia la nn <br /> Signed --r-- Title/Company 1"�"''i� r�Ae_u�/k (mo,,fe <br /> Print Name t i e r r� �/ (tT o f1�' `.� ic� /� Date F, < <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS,4eO S-/n�"' Sf �»ILc�J • !C SA 23 SU <br /> WORK PLAN DATED 30 2.6/D <br /> APPLICATION ACCEPTED B Aj DATA Itis UED ARE <br /> GROUT INSPECTION BYZ-E;LZ <br /> FINAL INSPECTION BY DATE J 2 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: 1 3 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> /bS $122x � 3��c8 !�}l`, C� �1 IG SR#00 0�?5_0 <br /> 0 ("j d 3 I ,��,bp0. d9 Roo IV <br /> 2 00 ��� <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 />