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o..g41''•"'• SAN JOAQUIN COUNTY <br /> FILE COPY <br /> a — ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> N � 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> •` , UNIT IV <br /> �,q.. ,;.••�P Telephone:(209)468-3454 Fax: (209)468-3433 Web:www.sictov.orn/ehd <br /> /FORM <br /> WELL & BORING PERMIT APPLICATION <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 Standardsof the San Joaquin County Environmental Health Department. 235 is a��na <br /> Site Location �� W' _ Cross Street (A44r-, . Ave— City TMCMZip �5_�M APN 23515 QR3 <br /> Property <br /> Owner ak�9 Address �+ City Zip 4 a► 7 Phone y��?-5Yy-&5t, <br /> C-57 Contractor QPnt(dtrG• Address 123,94AL Jfu{4A CityZ),0gd,(2Aj Lic9a6&?? Phone 53D-GG/'3GGiD <br /> Consultant/Sub CntrL MP(— Address CityC0.I<pltnd Lic(/DI%jQ Phone 510.663-9j.33 <br /> Billable Party Address 6101 20Itrroey i4 nYer .3 Qa City �w P-Qjmn Zip Sys Phone q.7-t- ;0O-64d7 <br /> GIS Coordinates:X 4• Y-IZ j.T 241 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEVA(WELUBORING(CPT,CZEOPR BE,HYIDOPVCnU ( RI) <br /> DdL, <br /> ,M— OIL BORING IDs <br /> WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE- ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS ^ TYPE OF CASING: ❑STEEL ❑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 FALLDEPTHIS 30 FT) <br /> —C]INJECTION(i.e.AirSparge.Ozonel,XHAND AUGER GROUT SPECIFICATIONS Tt�9 I-f l?oy jdIi d CQ—E] <br /> Q❑OTHER: ❑OTHER: APPROX.BORING DEPTH IXS_r ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> • I CONDUCTOR CASING XNo C1Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE ELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:rCHECK 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 ❑EXPLOSIVES FROM To FT BELOW SURFACE ?I <br /> TREMIE TYPE TO BE USED:ElAUGERS ElHOSE ElPIPE ❑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,an II applicab California laws. CC__11 `_�� � <br /> Signed Title/Company �cy4izi: /-4MzFG \1 <br /> Print Name t r� L Date � , ��/� <br /> DEPARTMENT USE ONLY f 1' Lp CJPA-4iac$ \ <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS I 1 <br /> WORK PLAN DATED If <br /> APPLICATION ACCEPTED BY DATE ISSUED AREAay <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <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 RO# INVOICE <br /> REQUEST I PR# <br /> 2aos $122 x "L I2- SR# O T Q <br /> �/�7 ! '�Z��� RO# <br /> 3500 <br /> 3�5. PR# <br /> 2900 <br /> C-57_�L_ WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-07 07/28/10 WELL <br />