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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <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.sInov.ora/ehd <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 Development Title.Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> ..sy <br /> Sita Location y6�t�o6 r) 99 b r [Dross Street t J,,r o;� . `�. Cit CT p `97-Zo <br /> iProperty �--b� Y 2i APN 0j+-010-oz. <br /> Ownor <br /> i}-ofo-fli- <br /> Ownor fie a{ Lia, L (as Address 414d MawsIZdCity sfd� lip 9'tO6Z Phone 65-0 _sz4-93Y'( <br /> C-67 Contractor <br /> i �r:ll_� Address �So ow� '� City Lic y6s/6S Phone YZS-313-57900 <br /> ConstrttarttfSubCntr 51fA Taos Address _ � :S�?y AF��-_--- City __ w__Ac.�. Lic 14A' mono yzl•4 T-y$� <br /> i <br /> Billable Party CJ�� �`y_' <br /> Y ld0'1 Address Wylg.A /Wc. City .lMrcn� Zip Phone 9�6+383"t}� <br /> GIS Coordinates:X -IZI. ASg Y 3S.tj Pb* <br /> WQORiSTRUCTION WORK TO BE PERFORMED: <br /> U RL LI-/BOWNG(CPT,GEOPROBE,FIYOROPUNCH.HAND-AUGER.OTHER) <br /> I's )RING IDS <br /> ❑WELL IDs -- <br /> ❑OTHER IDs _ <br /> TYPE&#OF WELL/BORING IN [ON TYPE CONSTRUCTION SPECIFICATIONS <br /> —Q MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS O MULTI LEVEL WELL CASING DIA <br /> n EXTRACTION:Vapor/Water ❑HAMMERJDRIVEN THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _Q SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF , SEAL TRI NPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> —_l SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED: No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ! <br /> i —O INJECTION(te.AkBnaae Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> (� —❑OTHER: ❑OTHER. APPROX 13ORING DEPTH OI,TEO TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING❑No[I Yes:Casing Dia: Cann the Bwing Dia; <br /> J <br /> I NOTE: OFFSITE WELLS Sr BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PER <br /> DESTRUCTION WORK TO Be PERFORMED: DESTRuMETHOD:(CHECK ALL THAT APPLY) <br /> *OF WlELL(S)TOOL• DESTROYED IJ OVER-BORE DIAMETER Or INCIICS'10 UEPTHOr Fl <br /> LL IVs. `vim W (Q PRESSURE GROUT TQ Dial>7i1 OF3-604'5 FT BELOW SURFACE <br /> GROUT SPECIFICATI 1JS w.a� EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS [I HOSE ❑PIPE MUSHROOM CAP AT(?3 FT) a A3 FT 9ELOW SURFACE <br /> COMMENTS W S d ti•w--(. - �.6o'acrs al+t,J-�_ ^' �S p4S <br /> ! T <br /> j 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared plication and that the work will be done in accordance with San Joaquin County Ordinances Rules and <br /> Regulations, 111cle C Ho is ws. - <br /> Signed01 <br /> Title/Company I _ <br /> Print Name <br /> Datet <br /> p DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ODRESS W 7 'f q P/ <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE ISSUED I L II AREA <br /> GROUT INSPECTION BY _ _ FINAL IN ION BY DATE <br /> DESTRUCTION INSPECTION BY DATE �� C <br /> COMMENTSICONOITIONS: <br /> ACCOUNTING ONLY: AID# _ _ FAC# _ <br /> PE CODES FEE INFO AMT REMITTED CHECK# -� RECV'D BY DATE -� SERYI E RO INVOICE <br /> D <br /> $122x 3 3(o{O / SR# 6 O{,44 O <br /> RO# <br /> fo `' ascot <br /> '�- PR# <br /> 2900 <br /> C-57 W'C WAIVER_ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD SM1MM0 WELL PERMIT APP <br />