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SAN JOAQUIN COUNTY <br /> I' •-ter ':Z.. LOP <br /> y R�' ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION <br /> 600 East Main Street, Stockton; CA 95202-3029 UNIT IV <br /> Telephone; 209 468-3454 Fax: 209 468-3433 Web:www.sigov.orcllehd� � <br /> WELL & BORING PERMIT APPLICATION <br /> ED <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION AUG U 8 2011 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andior install the work described. This application is m*WR0 NTA1..3"EALTI•I <br /> Joaquin County Development Title,Chapter 9-1115.3.and the Standards of the San Joaquin County Environmental Health Department. PE�R<M�IT/SERVICES` <br /> Site Location <.tJ f ICross Street VLTti,�C.�'1 City Zip 4533 to APN q2 <br /> PropertyM�� ��" (� -7 n <br /> Owner t `r�r.�,�S�Yc Y�G� Address�U1 YtJljtsc_ D►i JQ. Cityr Zip -l� o 3 Phon (tR .--a J 3 <br /> C-57 Contractor j�.:�/.1�1Aj,rY1(Et, ,1't1 Address Z �t Y .2.I City �'Vlc)1(�l,C�n Lic �2t 3L Phone�p �lt(Di'2�2 <br /> Consultant/Sub Cntr r7y L C!0KwI±Lj ,nAddress ZZS�b CC(.r l �t.7)] City <br /> '(n�A{vc. 'l�( is(05 �19 Phone�6[Z Ac,-(GJ�} <br /> Billable Party 1 Cw�vlia� 5 Address ? (UGvtiM,na r}ja.�.c CityWftµytGr�¢.� Zipr <br /> GIS Coordinates:X ' <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING[CPT,GEOOPR,BE.HYDROPUNCH,HAND-AUGER,OTHER) HU GUY <br /> "SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _.❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z lylc�-❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION:Vapor;Water ❑HA1v1MER•1DR!VEN CASING THICKNESS _TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _ <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL --14f� P,EMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> A_XSOiL BORING ❑PUSH POINT(GP!CPT) GROUT SEAL PUMPED..C1 Yes [YNO(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _p INJECTION(,.e.A.Soarae.Ozones❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑0'HER: ❑OTHER APPROX.BORING DEPTH __ <br /> _ � ❑BOLTED TRAFFIC BOX OR [3 STI PIPE <br /> COMMENTS: CONDUCTOR CAS NG 5jNo EIYes:Casing Dia: Casing Depth:__ Bohno Dis: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:I`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 BELOIV SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certy 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 C is I 1 �� <br /> Signed _ Title;Company-'4 M�•✓t•_'�-Mp- (',Q,� 'ifa As <br /> Print Name �Q.YM (oAASOIA- <br /> DEPARTMENT USE ONLY AA 'S <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 6100 SV reek e 16 �v u e _ man+e du <br /> WORK PLAN DATED r!� -1 -,'�D / <br /> APPLICATION ACCEPTED BYL4 1 f)r i Q )ne �/T n BG DAT1E!ISSUED IR-22 AREA 1+57q <br /> GROUT INSPECTION BY _ V Z aL"—?,4 14dA r FINAL INSPECTION BY DATE 8.26-//�� <br /> DESTRUCTION INSPECTION BYDATE__ <br /> COMMENTS/CONDITIONS: Advane elw _&tJ Sd t 1 <br /> ACCOUNTING ONLY: AID# FAC <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> _ REQUEST PR# <br /> j 29oS $129x 1 175-106) 3ggc _4 V M, -,:22 SR# 001,3248 <br /> 715- 00 3?-r" oo sO 000201 <br /> Soa. 6 p z 00) 05 L Ss-y <br /> C-57 WC _WAIVER _ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> E H D 23-01 07+28?10 WELL PERMIT APP <br />