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EC* fLE COPY <br /> SAN JOAQUIN COUNTY [\.U(; 29 2012 <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> R <br /> 1868 Hazelton Avenue, Stockton, CA 95205- ONIMENTALH[EtffE,MITIGATION <br /> �?ERN01ITISERVICES UNIT IV <br /> Tele hone: 209 468-3147 Fax: 209 468-3433 Web:www.slgov-orglehd <br /> P ) ) <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 Standards of the San Joaquin County Environmental Health Department. <br /> Site Location�tol Cross. City/States} �n Zip�Q� APN ISS 9�_fs <br /> Property �S�-+ � <br /> Owner 05GOL� '�. ��.Sb Address 53 ity/State Zip Q�Phone Epi-4 42- <br /> C-57 Contractor Rw�Core. Address mict City/State �-- �Phone <br /> Consultant/Sub Cntr p1RCAr)TL_C Address�� Qi;&)Rwza &;qC� City/State `Cit; Phone AZl_?A( - -49, <br /> Billable Party Address City/State �,a�lCA Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORk TO BE PERFORMED: <br /> [4 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> El SOIL BORING IDs !� h <br /> RWELL IDs X <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIE TION <br /> _MONITORING 44 HOLLOW STEM DIA.OF BOREHOLEPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _E1 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS=TYPE OF CASING: ❑STEEL [QVC ❑ 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 Sparge.Ozone)®,HAND AUGER �—GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASINGgEd N�o❑ es:C Ing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: 1 <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> L <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) r <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER of INCHES TO DEPTH OF FT t- <br /> WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE l l <br /> GROUT SPECIFICATIONS ❑ 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 preparq this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all applicable C orma laws. /� n <br /> Signed Title/Company <br /> Print Name a Date <br /> /l DEPARTMENT USE ONLY C <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS "lO 1 k), 56rd J65C S-79x%7— <br /> J �rdy <br /> WORK PLAN DATED -f�Cri1 2 U <br /> APPLICATION ACCEPTED BY I' DATE ISSUED AREA :/l! <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 PR# <br /> 3� SR#$,25x 3 <br /> Roo <br /> PR# <br /> �zsoo� <br /> C-57 // WC _WAIVERN�� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _��ENCROACHMENT DOC <br /> WELL PERMIT APP <br />