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� L <br /> FILE COPY <br /> SAN JOAQUIN COUNTY <br /> r ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> t"• � •t 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> \,��• �� UNIT IV <br /> .�•.,,-- k Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehd <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. •i <br /> Site Location�Al S&A JSr�—_Cro��reet City/State j Zip w6 L03 APN &'G_ <br /> Propert J a <br /> Owner. Address 4 �—��c�t ;ity/State�ak�RcZip <br /> q. ?,�Phone 2A _ 46Z.—� <br /> C-57 Contractor pe��y1C, Address IZ8 t3 acSt r�'iLr City/StateL6M Phone <br /> Consultant/Sub Cntr Address City/State!!Atk'! 4"c Phone Q? D� <br /> Billable PartyAddress ity/State j Wj Phone ,?��i.�� 0 <br /> GIS Coordinates:X Y CV�t,kl� <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GE0 ROBE,HYD OPUNCH A D-AUGER,OTH R) <br /> i�SOILBORINGIDS 6. �4 —Z.! —i��l AC AW US ( F1!tC� C1P1 aA' t6 <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑ MONITORING fflHOLLOW STEM DIA.OF BOREHOLE — ❑=TYPE <br /> CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor)Water ElHAMMER/DRIVEN CASING THICKNESS E�VG'{dw�KM TYPE OF CASING: El STEEL ❑PVC B OTHERQ <br /> —[I SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL— TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _RSOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:I5Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.Air Soarge.Ozone)❑HAND AUGER IN GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH %ij 115-9. ❑BpLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> to <br /> CONDUC OR ASING No[3Yeses:Casing Di;:y Ca Ing Depth: Boring Dia: <br /> COMMENTS: W.`k be A4ko <br /> NOTE: OFFSITE&LLS & BORINGS REQUIRE ACCESS AGREEMENTS O ENKROACY41MIENT 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 ❑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 prepay d this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable C ifornia laws. r <br /> Signed — — Title/CompanyiV ZZI <br /> Print Name leo d / Date8 f, 2-- <br /> DEPARTMENT <br /> DEPARTMENT USE ONLY _ <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS �L � A)' 'O N .IUSC S T 5 T(<"<T/U <br /> WORK PLAN DATED <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# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> pp REQUEST PR# <br /> $ 125 x ) d SR# tc <br /> qdS �-Z �zs (300 <br /> PR# <br /> 2900) <br /> C-57 WC 1/ WAIVER AJk_ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT 11ENCROACHMENT DOC_ [ <br /> EHD 29-01 5/09/12 VWELL PERMIT APP <br />