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rq�ln. SAN JOAQUIN COUNTY <br /> �aF+ .po <br /> 2 ' ENVIRONMENTAL HEALTH DEPARTMENT LDP <br /> IV <br /> 600 East Main Street,Stockton,CA 95202-3029 NIT SITE tMI MITIGATION <br /> Telephone:(209) 468-3454 Fax:(209) 468-3433 Web: wwW.s OV.or /ehd <br /> WELL & BORING PERMIT APPLICATION ECEIVED <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAR 0 7 2011 <br /> Application is hereby made to San Joaquin County fora 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 <br /> De <br /> P MONMENTAL HEALTHSite Location 3SI S NuNrY D — CmssStret L-1i0 � City�� m ZIPS20� 50 _2_ <br /> ukztc) .D Address�p{�o�L �k�ibCt Ciry}} N ZiP Zl PhoneL� -Zq* I'a ) <br /> C-57 Contra w 'f ? Address q,� Ih7sl�P <br /> ConsultanVSub Cntr () (P.L} C'ryh'py u� 5¢Z Phone -�fy t7v <br /> Address B4cLCt L2i d e�r� City SnN1 Lia <br /> Billable Parry Address Phone�O�'-Q3ti-•LLSc 4-0 <br /> GIS Coordinates:X Y City Zip Phone <br /> CONSTR TION WORK TO BE PERFORMED: <br /> NEW WELLfBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDS <br /> WELL IDs <br /> OTHER IDs <br /> TYPE&#OF WELUBORING <br /> M ALLAT16N TYPE CONSTRUCTION SPECIFICATIONS 1 <br /> _I]MONITORING HOLLOW STEM DIA.OFBOREHOLE R <br /> 4 <br /> ❑MULTIPLE CASINGS I MULTI-LEVEL WELL CASING DIA <br /> _jL EXTRACTION:Vapari water ❑HAMMERIDRIVEN CASING THICKNESS <br /> _O SOIL VAPOR PROBE TYPECASING: ❑STEEL UG ❑ OTHER_ <br /> ❑MUD ROTARY DEPTH OF GROUT SEAL-" l r TREMIE A <br /> TYPE TO BE USED: 0 AUGERS 0 HOSE PIPE <br /> __❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:D Yes PNo(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> INJECTION e.e ar Soeme .-e.D HAND AUGER GROUT SPECIFICATIONS •n rP •ri r r e -- <br /> _D OTHERS ❑OTHER: APPROX.BORING DEPTH <br /> BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: kr UCONDUCTOR SING No Yes:Cas Dia: Cas Dapth:_ Bad pia: <br /> NOTE: OFF TE WELLS&BORINGS RE UIRE ACCESS AG EMENTS OR NCROAC NT RMITS <br /> 44A�2= AM <br /> DESTRUCTION WORK TBE PERFORMED: DESTRucnoN MFTHnn• <br /> #OF WELL(S)TO BE DESTROYED THAT APPL9 <br /> WELL IDs: ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> GROUT SPECIFICATIONS O PRESSURE GROUT TO DEPTH OF Fr eELow SURFACE <br /> TREMIE TYPE TO BE USED.❑AUGERS ❑HOSE ❑PIPE El EXPLOSIVES FROM TO FT BELOW SURFACE <br /> COMMENTS ElMUSHROOM CAP AT L>3 FT) FT BELOW SURFACE <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> Regulations, <br /> I hereby certify that I have proparad this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> �and all applicable California taws. / <br /> Signed ,t t ,r,t "�I� — TjUe/Company <br /> Print Names _.r� _S <br /> yT DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS'�5I5 I Ib✓h1 ryµU.�, <br /> WORK PLAN DATED S 'J t0 <br /> APPLICATION ACCEPTED BY <br /> GROUT INSPECTION BY DATE ISSUED TO .7QU AREA <br /> FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY <br /> COMMENTSICONDITIONS: DATE <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# SERVICE RO# <br /> RECV'D BY DATE INVOICE <br /> 7 O $ i2Z Xa�.- p��OB REQUEST PR d- �'� ��'J SR&6ZI02--- <br /> R <br /> - <br /> 903 RD# <br /> 3500 <br /> PR# <br /> C-57 WC WAIVER 2900 <br /> FHD 29-01 07/29no C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> W ELL PERMIT APP <br />