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A � r€ . , .rz.. <br /> SAN JOAQUIN COUfIT�„F COPY0' 4 LU11 <br /> t °°a <br /> y ENVIRONMENTAL HEALTH DEPARTMENT ENliOPdf4A,— �. I <br /> 600 East Main Street, Stockton, CA 95202-3029 PGR%W, <br /> \ <br /> Telephone: 209 468-345 f <br /> cq� F ORN�F p ( ) 4 Fax:(209) 468-3433 Web:Www.sigov.orq/ehd <br /> WELL & BORING PERMIT APPLICATION Q p <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 4QL���rls 8tre�ett city APN23�'�s Q��- <br /> Property J '��� c, )(070I �l <br /> Owner Vl Address / yoo�puq��ns J pity X9 I42`Zip- Phone <br /> C-57 Contractor Address City 1md�Lic� 5J�i5 Phone' <br /> Consultant/Sub Cntr Address 210► /tblas{ �{ CityaCII Lic 6 01 YPhone - /� <br /> Billable Party �jrpn Ev,V Co Address (�Ini �A& City t t�Zip �J Phone�5_79 l07 31 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED:• <br /> NEW WELL/BORING(CPT,G�o�R`'OBE YDROPUNCH,HAND-AUGER,OTHER) <br /> [SOIL BORING IDs I N- �� —ray_ �� <br /> !❑_WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE—3"� ❑MULTIPLE CASINGS[I MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER c <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE V�\\ <br /> �IXSOIL BORING PUSH POINT(GP CPT GROUT SEAL PUMPED:❑Yes XNa(MAXIMUM FREE FALL DEPTH IS 30 FT) \3� <br /> _❑INJECTION(i.e.Air Sparge.Ozone;VHAND AUGER GROUT SPECIFICATIONS�i�(10 ���_ ^—�—'��,�� W)g t <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH BOLTED TRAFFIC BOX OR ❑STOVE PIPE A <br /> CONDUCTOR CASING)<No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: I� t <br /> NOTE: OFFSITE WiLLS& BORINGS REQUIRE ACCE 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 Fr <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROMTo FT BELOW SURFACE <br /> CO MIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE 1 <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,a all applic le Cq(ifornia Laws. <br /> Signed - 1� Title/Company_��a_-� ZAJJ c <br /> Print Name � 2,`Qrt .L!/2`fYi(� Date //1 <br /> DEPARTMENT USE ONLY4 <br /> Jj <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS .�Q� <br /> ! v •�'_� " fes/ <br /> WORK PLAN DATED Jr <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY: DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC r <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BYJ;41ASERVICE RO# INVOICE <br /> c _ REQUEST PR# <br /> O $125x 1ZJ <br /> 3�S <br /> ) <br /> PR# <br /> 29110 5 5�'S' <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT EN EN DOC <br />