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FILE COPY <br /> �o.t'a ,co SAN JOAQUIN COUNTY HECEID <br /> ' ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> w�i, JUN 2011 <br /> • '�' 1868 Hazelton Avenue, Stockton, CA 95205-6232 _SITE MITIGATION <br /> Telephone:(209) 468-3147 Fax: (209) 468-3433 Web:wwuc.sax.oru(ebd UNIT IV <br /> HEALTH <br /> WELL & BORING PERMIT APPLICATIMMIT/SERVICES <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 Location ab?�3 OLC-t ilC�Av-F— Cross Street BC6a -4N Eb 14-0,,, City/StaleSbckPA l ip -07 APN D]—t 10—L Eg <br /> Property L mcoln 1>ybptY'tVS L-1d <br /> Owner 61ztA'i6V&*A Q1 t —'Address PQ &D)( l City/State 14 Zip91412Q Phone <br /> C-57 Contractor NQS j T---W 0 Address .GuO�, 6. I a;je) S-� City/State �C tO c (0S Phone G30'(,oI62,1 2,9 <br /> Consultant/Sub Cntr4QC Address, 51� C1 Ye- CD City/State ( G`Lic PhonI C <br /> Billable Party Address City/State Zip Phone <br /> GIS Coordinates:X 8-VI V Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> EW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> OIL BORING IDs RA- I + CAA -2 , 3,4-3 <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _E1 MONITORING C10LLOW STEM DIA.OF BOREHOLEt ` <br /> O MULTIPLE CASINGS DMULTI-LEVEL WELL CASING DIA: <br /> _D EXTRACTION:Vapor!Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _O�SOIL VAPOR PROBE D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS D HOSE [IPIPE <br /> aEKS-oIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _D INJECTION(Le Air Soaroe.Ozone)D HAND AUGER GROUT SPECIFICATIONS <br /> r <br /> _D OTHER: ❑OTHER: APPROX.BORING DEPTH J 0 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING[INo❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> NOTE: OFFSITE WELLS Sr, BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <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: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS p 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 applicable Ca" rnia laws. <br /> Signed r Titie/Company 5 f d 1 <br /> Print Name 1 A-,J �J- f Date Z (� <br /> / DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS P(k'l Ft 4 <br /> WORK PLAN DATED J L.(, - <br /> APPLICATION ACCEPTED BY d 6'4ck"\ DATE 1 EA 1/6797 <br /> GROUT INSPECTION BY FINAL INSPECTION BY TE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE Rio# INVOICE <br /> REQUEST PR# <br /> �4v5 $125x CY] L432'Zr-)Z_ dfC<wrtk G-q-(`i SR# <br /> 29CU '2 7� RO# <br /> 3500) <br /> PR# <br /> 2900 <br /> C-57 r/ WC ✓ VVAIVER 4— C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT t/ ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />