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2?°P4�rFr'FpG SAN JOAQUIN COUNTY ORIGINAL <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone: (209) 468-3147 Fax:(209) 468-3433 Web: wWw.s' ov.or /ehd UNIT IV <br /> Iq p <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[thheq Standards of the San Joaquin County'Environmental Health Department. <br /> Site Location 2N� &. V�- Cross Street \ \�^ ��• city/State '4-.1^vAZip APN \4\�2L�o•—L3 <br /> Property , (` <br /> Owner ,71��P) ulv c� �-Address 2�0}F •`' Mn�& City/States"�.ZipC��Phone <br /> C-57 Contractor �� Tddress 'CC,O • CitylState _ 4 +4kic �Phoneq\ � <br /> Consultant/Sub CntJr ))Address City/State^ Lic Phone �` L{ <br /> Billable Party �( f\QSC C Address /- ¢�, <br /> Si1l )C � City/Slate ZipA1A5_�Phone <br /> GIS Coordinates:X allyg6-hv\\ Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPR BE,}iYDROP NCH,HAND-AUGER,OTHER) <br /> SOIL BORING IDs \ ,S "L. S ?� <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SP <br /> ECIFICATIONS <br /> _❑MONITORING El HOLLOW STEM DIA.OF BOREHOLE'1.t- /I❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _O EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> —❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> V11 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i as o )'(IAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH �'Cl ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> 4 CONDUCTOR CASING❑No❑Yes:Casing Di Casing Depth: Boning Dia: <br /> COMMENTS: � \ ,� S <br /> NOTE: OFF ITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PE61TS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD,(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: El PRESSURE PRESSURE GROUT TO DEPOF 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 /> I hereby certify that I have prep r@d this application and that the work will be done In accordance with San Joe uin County Ordinances, Rules and <br /> Regulations,and all appticabl Califor la lbws. <br /> Signed % C Title/Company 's •\`fes+.' �O DQ-w 3, O C- <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS iZ 4I78 C aHX -z�TQg��7-f �;76 <76A) <br /> WORK PLAN DATED JLt K, <br /> APPLICATION ACCEPTED BY j-NA1�:4 U,,A DATE I EA 14 41 <br /> GROUT INSPECTION BY V FINAL INSPECTION BY .J y �Q GF oAT�v <br /> DESTRUCTION INSPECTION BY DATE <br /> COM M ENTSICON DI TIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> �s $ ,25X 125- 7 7qZ � Iti SR# 1990 <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57_t�_ WC ✓ WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ / - ENCROACHMENT DOCA/4 <br /> EHD 29-01 5/09/12 <br /> WELL PERMIT APP <br />