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ORIGINAL <br /> C; <br /> !a., SAN JOAQUIN COUNTY <br /> Z 1A <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> a: <br /> IT GATION <br /> `.�� � 600 East Main Street, Stockton,CA 95202-3029 <br /> a _: Telephone: (209)468-3147 Fax:(209)468-3433 Web:www.sogov.org/eh <br /> #. '' <br /> ...,dtii <br /> WELL & BORING PERMIT APPLICATION APR 3(� 7 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT I. <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made Inj0L3R?A"j8 <br /> Joaquin Counly Development Tille,Chapter&1115.3,and the Standards of the San Joaquin County Environmental Health Department. �^1��QQ/,7 --$ <br /> ��.y ��11 -I' 171 L' Cil U zip—9.5.5 APN <br /> Site LoceCl 'dN17� Cross Street `1 o Y <br /> Property�- r^Y G�/ Address ' 7 6O - Cily ref C Zip S� Phone f'35-65 <br /> C-57 Contractor FS1� 11, Address yr <br /> city f P✓!� LIc lPhon `3 I <br /> Consultant/Sub Cntr Address City f tic !:�`. Phona 576V <br /> Billable Party Address City (.(. Zips Phone S)I ' IN) <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ElNEW W ELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HANPAUGER,OTI/ER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _I]MONITORING G HOLLOW STEM -DIA.OF BOREHOLE_ G MULTIPLE CASINGS G MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water D HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC G OTHER <br /> _G SOIL VAPOR PROBE (I MUD ROTARY DEPTH OF GROUT SEAL TREMIETYPE TO BE USED: GAUGERS ElHOSE GPIPE <br /> _0 SOIL BORING D PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yea G No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ,_D INJECTION fLLALWLo­Q=ad G HAND AUGER GROUT SPECIFICATIONS <br /> _D OTHER: D OTHER: APPROX.BORING DEPTH El BOLTED TRAFFIC BOX OR ❑STOVEPIPE <br /> CONDUCTOR CASING D No G Yes:Casing DI.:_Casing Depth:_Ba!ng ON:. <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD•t Qlsl 6,LTHAT APPLY) <br /> _�.JI # FWELL(S)TOBE DESTROY��j/��,. ..�s //�� /n� ,s. I OVER-BOREDIAMETEROF, , NCHESTo DEPTHOF�FT <br /> WILL IDS: IY111�.W�T MI.J}L'� Nc5'Te� ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS �iL./I - �'7iG L-' A ren ❑F>CPLOSNES FROM TD FTSELOWSURFACE <br /> TREMIE TYPE TO BE USED:[]AUGERS ❑H SE PIPE n r° ❑M}1SHROOM IT AT Q3 F7�) FT BELOW SURFncE <br /> COMMENTS t5 t"5 'S1 e �O(sr i7')Y7 a-I-il1 ne.r.tn,uX� "r(i4}v Fa <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> 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,and all appli Ie Californla laws. <br /> /T TIlle/Compam/ <br /> Signed <br /> Print Name — (`1g✓t /!'1<f/1 "aleTC)--)�- <br /> �i DEPARTMENT USE ONLY - <br /> SITE MAP IN UNIT N FILE-SITE DRESS <br /> WORK PLAN DATED 7 APPLICATION ACCEPT B DATE ISSUED AREA <br /> GROUT INSPECTION a FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> S-E-R-V FRO# INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST /PR# <br /> moo? $125x � r00 3 0 SR#COC, P09 P <br /> 3� -00 <br /> PR# <br /> 290a <br /> C-57 WC _ WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENVT�DO PERMIT APP <br /> EHD 29A1 01113/12 <br />