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p4 t" • SAN .IOAQUIN COUNTY C 0 <br /> �r�-D <br /> ,q. so c. <br /> —`r Y, <br /> ENVIRONMENTAL HEALTH DEPARTMENT L P <br /> 1868 Hazelton SITE MITIGATION Avenue, Stockton, CA 95205-6232 UNIT IV <br /> "4t FsRi;:a Telephone:(209) 468-3147 Fax: (209)468-3433 Web:www.sigov.org/eh <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 9-1115x.3,and the Standards of the San Joaquin County Environmerital <br /> it Health Department.CA y Z �7 r� <br /> Site Location3931 geut�anl CrDos�s Street City/Stale ��AToN Zip g' -2 APN I✓p f���' ` <br /> Property t <br /> Owner_ Kcxj C-, e--C'--C' Address)-/p 3/ NeuJ-16,J ,PDaD Cty/StateS�6-Ay-j9f^��Phon 46 �� <br /> C-57 Contractor /O/A Address City/State Lic Phone <br /> Consultald/Sub Cntr.S.(, , 0\,IP- Address Tb B0%. )/5z Wd /� yls� F46CIxz4 Phone zD9- 369-9Y2/ <br /> Billable Party S, 1i, /V�V/,e Address 4 S alb6 U e✓ City/Stale Zip Phone <br /> GISCoordlnates:X Y -fa(. �S 'C4- t-!&,Re I �F orefc�l�v7 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER OTHER) <br /> SOIL BORING IDs 4,7-- S 9/S <br /> WELL IDs <br /> ❑OTHER IDS tine <br /> TYPE&#GF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECLFICATIONS L7 V <br /> r <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS 0 MULTILEVEL WELL CASING DIA: 4/! <br /> _❑EXTRACTION:Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ,h <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> 1; <br /> 2gSOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes 5No(M�AXIMUM FREE FALL DEPTH IS 3,0[ <br /> �_❑INJECTION fl.e Ai,Svonn,0z ) .HAND AUGER GROUT SPECIFICATIONS 60C-kr'// W to "'b' <br /> ❑OTHER: ❑OTHER: APPROX BORING DEPTH 10- ffl- ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> v(.2 17/i T <br /> CONDUCTOR CASING El 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 [I <br /> OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> W—ELL 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 L3 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 he done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,annd,911 appligable Califor�nria laws./ /' / � <br /> Signed /6t--��' - '� l`i- •,,!`''I �'T TitlelCompany ��N E/� -5 i v/Q- l�Qa6F ` <br /> Print Name > a/ /LI�LJ - Date <br /> DEPARTMENT /U1SE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS J t � 1 <br /> WORK PLAN DATED 00 Q <br /> APPUCATtON ACCEPTED BY ,T/9f� DATE ISSUED /�'/�l'/ AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE _ <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDfDONS:. <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 35bS $130x � V �folU E�27- !G'�r7 SR# 7!562 <br /> RO# <br /> 3 � 3 Ya 3500 <br /> PR# <br /> 2900 <br /> C-57 ✓ WC V WAIVERa/fill/f = C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 7/24/14 WELL PERMIT APP <br />