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PRDry' • SAN JOAQUIN COUNTY 11 Cory <br /> m ENVIRONMENTAL HEALTH DEPARTMENT <br /> A LOP <br /> ' 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> P Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.siaoy.org/ehd UNIT IV`-.,, r r7 <br /> �iFOR� <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 /> Site 3 iS 9� 1 ham. t,.,t,," <br /> Property <br /> V1cU Cross Street t '���ry \ S�-• City/State\ QC'A AZip S?Aj qpN \L-(\^2-to—2--:; <br /> bZ�Owner-7 �' ` «-gddress <br /> nSvfllCity/State v Zip S-"u PhoneC•57 ContractorCa y,A(z !Tddres5 as 0 City/State Sc wV 4,ic 22�9)I q Phone <br /> ConsultanUSub Cntr e <br /> - ddress " City/State �Lic Phone <br /> d(�}� <br /> oC=D�Lt s'— <br /> 3 <br /> BIIlable Party �SSO ` , Address CQA j$ \W City/State _ ..�C Zip Phone !:4.24 I1 _ <br /> GIS Coordinates:X 32.114 o\\ Y — \2\% 2C62c4�- <br /> CONSTRUCTION WORK TO BE PERFORMED• <br /> ❑NEW WELUBORING(CPT,GEOPR BE,� YDROP NCH,HAND-AUGG,ER,OTHER) <br /> SOIL BORING IDs c'�^\ S` ^Z S'V, <br /> ❑WELL IDs '�—I <br /> ❑OTHER IDS <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> —E]MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE-4'TtVI 0 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water 0 HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: [ISTEEL 0 PVC 0 OTHER <br /> _0 SOIL VAPOR PROBE [IMUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS 0 HOSE 0 PIPE <br /> t!Q SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION O.a A aRsML O�AND AUGER GROUT SPECIFICATIONS <br /> _O OTHER: 0 OTHER: APPROkIkO�EPTH_ \'R ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDt�C70R CASING❑No 0 Yes:Casing Die: Casing Depth:_ Boring Dia: <br /> COMMENTS: \ S <br /> NOTE: OFF ITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT P MITS <br /> DESTRUCTION WORK TO BE PERFORMED: REST! QION METHOD.,rCHECKALLTHATAPPLVI <br /> OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDS: <br /> GROUTS [IIFICATIONS PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> PECEl EXPLOSIVES FROM To <br /> COMMENTS <br /> TREMIE TYPE TO BE USED: AUGERS HOSE PIPE El MUSHROOM <br /> BELOW SURFACE <br /> MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prep d this application and that the work will be done In accordance with San Jos uin County Ordinances,Rules and <br /> Regulations,and all applicabl Callfor la I ws. <br /> Signed C Title/Company's- AiDe 't oC� <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED JJAPj l /C/ <br /> APPLICATION ACCEPTED BYDATE I t" -*RIEA 144 <br /> RH'l '�rwdt ,'� <br /> GROUT INSPECTION BY 6t. GOA-ZAICY FINAL INSPECTION BY Cj. Gon al(Z DATE <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 /> -iqap REQUE/ST(1I PR* <br /> s S125x Z 77 11n�7� SR# <br /> RO# <br /> 3500 <br /> PRO <br /> 2900 <br /> C-57_� WC ✓ WgIVER� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT /� ENCROACHMENT DOCAiA <br /> EHD 29-01 5/09/12 <br /> WELL PERMIT APP <br />