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,¢�" .•..a� fb SAN JOAQUIN COUNTY IS FILE We y <br /> .y ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3147 Far(209) 468-3433 Web:www.sigov.org/ehd <br /> </FpR <br /> WELL & BORING PERMIT APPLICATION APRA4 2014 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <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 Department. <br /> Site Location V110-k"(k5e; ?� Cross Street&', °ZY- t!-(? City/State[, ti,P.-n(','' Zip 1 330 APN 1 17S' D 1 n I(: <br /> Property r� <br /> Owner Address( r''J 1)1^M�i,f','S Zip (OT C19 Phone'ID 14-J&LI <br /> C-57 Contractor(-,Yt-E.t,(>,Oc-ou.,.,t Address q54 4R.,-r"> jt.0 A,-r. City/State +R nos 1ALic tri Phone <br /> Consultant/Sub Cntr Address City/State Lic Phone <br /> Billable Party Address City/State Zip Phone <br /> GIS Coordinates:X o Y -12 1.271.0 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Ik-.s_A❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> [>d EXTRACTION:Vapo Na Rr ❑HAMMEWDRIVEN CASING THICKNESS SC.{(,•IN PVL TYPE OF CASING: 0 STEEL ISttl PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE 4 MUD ROTARY DEPTH OF GROUT SEAL 5£E F IGY TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE 14 PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:®Yes ❑No((MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _I]INJECTION(i.e.Ml SO.Me.Ozone)❑HAND AUGER GROUT SPECIFICATIONS t'Sf v / f c <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH CF�Q FIC-1,0-P-S ❑BOLTED TRAFFIC BOX OR V STOVE PIPE <br /> CONDUCTOR CASING C .No Yes <br /> COMMENTS: 6 Yes:C Casing Depth: Boring Dia: <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 WELLS)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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California laws. <br /> Signed 'T/�f., --,.-�--/'r/!/d.-. 5-s+--� Title/Company <br /> Print Name /.�,<�-4s� /. w qi TDate_ <br /> C DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS r�J I\O J l-I e'0 D 1 /-4TM O�y P <br /> WORK PLAN DATED PQf ,A `I 2vf'-! <br /> APPLICATION ACCEPTED BY .I-'f O4KuW\ DATE"' _ AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY �O�7CtrM - ATE> 3 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE Ro# INVOICE <br /> pp7 REQUEST PR# <br /> �7U / g 125 x17l.�Z �[,E{_ "�y SR# (� <br /> ZpU 37s RO# <br /> ll 3500 <br /> PR# <br /> 9-00 <br /> C-57_ WC V WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT d ENCROACHMENT DOC A,1fj <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />