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jkCEIVULE COPY <br /> Pa '" SAN JOAQUIN COUNTY LOP <br /> ENVIRONMENTAL HEALTH DEPARTMENT FEB 09 JbISITEMITIGATION <br /> 600 East Main Street, Stockton, CA dq. 95202-3 L029 CE,,� ,�1,NIT IV <br /> ,e Telephone: (209) 468-3454 Fax:(209) 468-3433 Web: <br /> <IFORa !ICES <br /> WELL & BORING PERMIT APPLICATION V <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (/{U <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 Z9C)S 49W Cross Street, 10/x^ '/ q City 1NUId•�Er..b4 Zip4 S APN Z 2� - 7 OD �7 <br /> Property.�r� /qp0 /(1/G��fr/rCSGY c' r� <br /> Owner l �r.T 'ZRIP Address City, Zip. JST�0 Phone <br /> C-57 Contractor )_- ,�-Address Ir D I u1 e, t City Phone j—'S( D cyc/F/Z <br /> Consultant/Sub Cntr Address City Lic Phone <br /> Billable Parry Address p City Zip Phone <br /> GIS Coordinates:X Y —4,zl. 114i <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHERIDs <br /> TYPE&#OF WELLJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: OP <br /> _❑EXTRACTION:Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL Cl PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e Air Scams,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: Baring Dia:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& 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 TO FT BELOW SURFACE <br /> GROUT SPECIFICA IONS 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 Calliifloornia laytvts. <br /> Signed �\ hk UU I-A Ci. Title/Company [N{moi P Oy <br /> Print Name I A k ri_� c5 TRA.)COk Date <br /> DEPARTMENT USE ONLY � � � � � � �7 Z9-loU <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS l8 e�0 ^'�� lu_ � <br /> WORK PLAN DATED _F1// <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY 14 FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSMONDITIONS: .I.u- !�orl• <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BYDATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 2902 $122 x ( /zL // SR# 062-17- <br /> 90 3 U106,6 35 # <br /> PR# <br /> MTL 2900 <br /> EHD�29 01 o7/2ano C WAIVER C-57 LETTER OF AUTHOR) [�1 TjIGN1 O1 Bfdt?R6AC�olEltl7"DO PERMIT APP <br />