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oeq�.... � SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENTEkUTH <br /> �.,� <br /> y'. P 600 East Main Street, Stockton, CA 95202-3029 1�UlS�Y� ��VIiT AF <br /> . �;.,. �..•;P. Telephone:(209) 468-3454 Fax: (209) 468-3433 Web:www.smqov.org/eh PERM AWMICES- <br /> {,�o Sit► <br /> WELL & BORING PERMIT APPLICATION <br /> 1LE � � <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIA O <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> rr <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, <br /> Cahter 9-1115.3,and the Standard of the an Joaquin County Environmental Health Department. <br /> 238 G QQ�0 �7�a <br /> Site Location` !L Cross Stree G t City G Zip9 � APN <br /> Property r6 (� b <br /> Owner 5t� � �" Address 7' � City Zip ( Phone <br /> C-57 Contractor AA e/1C e&O Address G� City c Phone Ko() P <br /> Consultant/Sub trA a Address 1 City Li,�Q Phone &1610 91_93 X <br /> Billable Party f'1�(�66� Vt Address i, j— — City Zip qua l�Phone 51 f <br /> GIS Coordinates:X 37 _ Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GEOPROBE,H ROPU CH,}1AnI�AUGER,OTHER} <br /> NSOILBORINGIDS, _ ::20 lnrr.,t55 king A�s� <br /> WELL IDS �_ <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE "}sl MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> _❑EXTRACTION:Vaporl Water ❑HAMMERIDRIVEN CASING THICKNESS WA TYPE OF CASING: ❑STEEL ❑PVC 17-1 OTHER „((r���((r�������uu <br /> 19,A SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL =TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE r 1 <br /> _❑SOIL BORING PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Y s ❑No(MA MUM/FyR�EfEf FALL DEPTH I 30 FT) / �+ �►r ,I <br /> _❑INJECTION i. Airs a zone ❑HAND AUGER GROUT SPECIFICATIONS <<{✓) `?`�`_4 _PEr 6 ! Cq/XghS w7 4`'r W <br /> { <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Dep(h: Boring Dia <br /> COMMENTS: 0f ba Q 0 Q) <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS Gt <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY <br /> T#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL 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(>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 prepared this application and that the work will be done In accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all app ble Calif rnia laws. �} r , ] _ �y <br /> Signed Title/Company Uf t3�/l 0 /.�7f A <br /> Print Name op Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 257 3 I _r}• <br /> WORK PLAN DATED tJ{lt+y 20 / 0 <br /> i <br /> APPLICATION ACCEPTED BY VI&.-hrr,`,a d)2G['� rfn e c r _ DATE ISSUED !?-7-10 AREA <br /> GROUT INSPECTION BY Y j Qijril�Gt �LdQv! � FINAL INSPECTION BY�Vie 42M64r4hXk ATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: C , 4'f ba r r` f' <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK#" RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> SOS $122. 1 I.Z z , 0 0 3142 L p SR#OD R <br /> ..350 3 3GL-0 d �3GG . D 0 Rao 6 7 <br /> PR* <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28110 WELL PERMIT APP <br />