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SAN JOAQUIN COUNTY ORIGINAL <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigra <br /> ov.oleh UNIT IV <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED T <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,Ch pter 9-1115.3,and the Standards of the S n Joaquin County Environmental Health Department. <br /> Site Location Crass Street fo 4on'� city Zip !-%�377 APN `2 <br /> Property F ,,G <br /> Owner QS y� (-Mj 5 Address 7Gv City 11 A1C Zip 77 Phon •+�f �� <br /> C-57 Contractor, t- i Address `j. l f50'I Q city -5c c /t7 L' Lic�Phone 9 3��3 <br /> ConsultanVSub Cptr �Gqv ig0 02W%ddress c32'�Ci+r1Gti✓ City S J'1 Lic�Phone [U . 1 I'(i 3 CD <br /> Billable Party d�u� 6 CeOj�-na, Address q3-7 5b►�.�r City Si Zip'9-r,915- Phon 511 -9Jw <br /> GIS Coordinates:X3-7- • 10 Y ld-UAlt�fog <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE 8#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS RR <br /> _❑MONITORING [I HOLLOW STEM DIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LIKPIL-Fis������ <br /> 3DIA: <br /> ❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CAStNG:_Ej STEEL{{{❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO PIPE <br /> PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP!CPT) GROUT SEAL PUMPED-[I Yes [I No(MAXIMUM FREE FALL D s�sIA0`l�)9VICES <br /> _❑INJECTION(i.e.Air soarae_ozone/❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX,BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑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: DE TRUCTION METHOD: CHECK ALL THAT APPLY) �p <br /> #OF WELL(S)TO BE DES ROY OVER-BORE DIAMETER OF t INCHES TO DEPTH OF [ ` FT <br /> WELL IDs: k2- Ill-1 lJ D ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ~-C 4VO ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREM[E TYPE TO BE USED: AUGERS ❑HOSE ❑PIPE g ❑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 able California ws. <br /> Signed Title/Company 67P-0)eO t5+Wan-'Id4 6CaI-5�4 U1� 1�1Pn/T <br /> Print Name rl,a4n r � Date Q '15-- 23 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS Z o TdKT 7F RJ. 7-IQ+9,,IN 1 <br /> WORK PLAN DATED I:, 20 Ok <br /> APPLICATION ACCEPTED BY S-`� KuW DATE AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY .;-��ATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: 311 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE' <br /> �1 <br /> REQUEST <br /> / PR# <br /> SO Z $125 x 2 ��e S .L•fs'15 SR# 10toto <br /> RO# <br /> (3500) <br /> PR# <br /> 1 2900 <br /> C-57 JZ WC bi WAIVER [ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT -y ENCROACHMENT DOC AIR <br /> EHD 29-01 01/13/12 WELL PERMIT APP <br />