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SAN JOAQUIN COUNTY <br /> FILE UPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> I 1868 Hazelton Avenue, Stockton, CA 95205-6232 517E MITIGATION <br /> \'•, UNIT IV <br /> Telephone:(209)468-3147 Fax: (209)468-3433 Web:www.sigov.orpiehd <br /> /FOR <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 pemnrit 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. c� <br /> Site Location L3 011lVy'k. G`CI Cross Street •cl City/State 4LQmhpd Zip t7 � APIN <br /> Property--7 �7 <br /> Owner /Yk{7r i r Address l i��/�'$h y�GJ City/State /7YGnrJ Zip %;ZZU Phone 24,x/'3;3- <br /> C-57 <br /> ;3.C5!Contractor rf nJ Address L! /I�L�+� /Sf �'�'S� City/State(t/l611`L Lic d�� Phone SSS/ /%bz/-ZLc <br /> Consultant/SubCntr Address 1710 City/StateL[:' 4 ,t4 Lic Phone 4?,500' C(Y,D <br /> Billable Party l-�(i6,141W,, Address the. ctS iIXV� City/State Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> SOIL BORING IDs S51 -11-,r)j-�,H SES '-1 <br /> WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS A <br /> —[:]MONITORING [IHOLLOW STEM DLA-OF BOP.EHOLE z-)N"U MULTIPLE CASINGS❑%1ULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor)Water ❑HAMMER/DRNEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TP.EMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> -,0 SOIL BORING VPUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑'Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ❑INJECTION(I.e.AirSpa(ae Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPP.OX.8ORi1dG DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> nom'. CONDUCTOR CASING❑No E3 Yes:Casing Dia: Casing Depth: Boring Cia: <br /> COMMENTS: IJu�^5� r✓�� �G{J del (yYt � WI rlt�.1 Cdivt�nt etre t'L V3 <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:rCHECK ALL THAT APPLY) } <br /> #OF WELL(S)TO SE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT C•• <br /> WELL IDs: 40 I 17 ��n a� ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS JA 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 lifomia laws. <br /> Signed Title/Company Ll C��✓Cj Jr /i�f—�✓ %`� � <br /> Print Name Vin�G`r Date 11/z <br /> DEPARTMENT USE ONLY o <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 2 I 3 <br /> WORKPLAN DATED <br /> APPLICATION ACCEPTED BY O✓;Kv P- DATE ISSUES {�'��'/e' -AREA /6 <br /> GROUT INSPECTION BY FINAL INSPECTION BY LJAk <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICO N DITI ON S: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 5 $125X L<-d7- 12-r1-.1Z SR# (r <br /> Q _ RO# <br /> (3500) <br /> PR# <br /> (2900) <br /> C-57 ✓ WC ✓ WAIVER tel/(g C-57 LEITER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC— � <br /> EHD 29-01 5/09/12 WELL PE(yRMIT APP <br />