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VAY11PiCIV 1 <br /> PIECEtl9E <br /> SAN .�OAQUIN COUNTY iJ�i"1,p, 0 5 2053 1 E DOPY <br /> Nati - ENVIRONMENTAL HEALTH DEPARTMMCOUNrr Lop <br /> • ��`� 1868 Hazelton Avenue, Stockton, CA 95205-Cj 'vtRoMENTnL RTE MITIGATION <br /> ` Tli DEPAFtTME <br /> Mone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehd UNIT IV <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. C �/ <br /> Site Location k`A C L>k%- S <br /> =- Ch\;t!r__Cross Street J, Lti-�,N\e_Lia City/State C�c�,Chip �l S��-1 APN �d 1-�yU'z 7 <br /> Property <br /> �e.cC�7h��- <br /> Owner C-JI ��`CS� LIr�}��^e{' Address �'f)� 1��C�q�` v1,`N­,WCity/State r11 �Lipy�:;.s� Phone <br /> C-57 Contractor Address City/State Lic Phone <br /> Consultant/Sub CntrQ.� ')eC V tic Address _K1 2,4 b L .Au=1, \moo City/State ', 4' Lic�S,,�Phone <br /> Billable Party S, Lv 2.1c. Address )L-1%,A6 E- [�_ 1 ZQ� City/State E~`^ Zip CK SZb Phone Z04-839.1N?_ <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <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 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN 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 FALL DEPTH IS 30 FT) <br /> ❑INJECTION(i.e.Aar Soaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: D STRUCTION METHOD: CHECK ALL THAT APPLY <br /> A #OF WELL(S) BEDF�STROYED OVER-BORE DIAMETER OF 1 INCH TO DEPTH OF -73. FT <br /> WELL IDs: A— ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS 10 C" ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS WOSE ❑ PIPE WUSHROOM 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 t tat I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulati an all applicable California laws. <br /> Signed C-r—,' Title/Company C�ct Q J. <br /> Print Name I O to M CCw Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS /y 700 Lc,, SC�1�47 <br /> WORK PLAN DATED 3 <br /> APPLICATION ACCEPTED BY DATE IS _ANEA I6 9C1 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE 2?r/ <br /> DESTRUCTION INSPECTION BY CA 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 /> Gq bZl $ 125x I�t7 SR# <br /> 7J��j X75 RO# <br /> (3500) <br /> PR# <br /> (2900) <br /> C-57 X WC _WAIVER A.)�+ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT k ENCROACHMENT DOC Aht <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />