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•, SAN .JOAQUIN COUNTY <br /> r. ENVIRONMENTAL HEALTH DEPARTMENTLOP <br /> SITE MITIGATION <br /> 600 East Main Street,Stockton,CA 95202-3029 UNIT IV <br /> •.- Telephone: (209)468-5454 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIO <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicatio hereby made to San Joaquin County for a permit to construct and/or install the work described. This application I ade In compliance with San <br /> Joaquin Cou velopment Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health artment. <br /> Site Location W• cs M moss street FISH(TAC-I<dLR city t0rV RCA• zip �T? APN 240 '(b'a--T 4 <br /> Propertyr� <br /> Owner I� S£ BMJ dress i KA-1,176a A-4%4 City 04k 4wfl Y6(� Phone 3-14-2-71- ST/o <br /> C-s7 Contractor —6 0 Address S 6 z I V6 tL A, Al o VI J'TA Lie 1�O 0 Phone?61—STY,Y.�d a <br /> ConsultantlSub Cntr AO Address-TO)-O Pli t©LA"9-OK, City XA-CA Lie 133Yft Phone q 16 ?5'-7—14-o <br /> Billable Party FACT P—Is. Address J A AS AiTavccity Zip Phone <br /> GIS Coordinates:X 37 1'1'7 q N, Ill. 1 <br /> CONSTRUCTION WORK TO 13E PER E • <br /> NEW WELLIBORING(CPT,GE ROBE HYO U H HAO HER) <br /> 0QOIL BORING IDs —t <br /> ND A GE'!M <br /> WELL IDs <br /> ❑OTHER IDs ' <br /> TYPE&0 OF WELUBORING INT TI N CONSTRUCTI N CIF CATIONS <br /> _,❑MONITORING ❑HOLLOW STEM DIA.OF 80REHOL �•�T ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA-- <br /> _[I <br /> IA:_❑EXTRACTION:Vaporr Water ❑HAMMERIDRIVEN ASING THICK S ,_TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY D OF G UT SEAL 'T 0 REMIE TYPE TO BE USED: ❑AUGERS ❑HOSE (PIPE <br /> R�XOIL BORING "PUSH POINT(GP/CPT)�j GRO PUMPED:❑yes ❑No(MAXIMUM FR EUALLQQEPTH IS 30 FT <br /> _❑INJECTION(I,e,Ajr Soame Ozoner RANO AUGER W43. Z GROUT ECIRCATIONS Y6f�T�'�AiQ S V /• .I� 1m <br /> _❑OTHER. ❑OTHER: —'T'APP X. ING DEPTH 17 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> r1 DUCTOR ING(B.No❑Yes:Caypg 01181 Casing Depth, Boring Dla: <br /> COMMENTS: Y —J 4J r I G �G P r.d CT . vC P <br /> NOTE: OFFSITE WELLS all BORINGS QUIRE ACE�El AGR EMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: bw 3:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED OVERBORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDS: ❑NESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS [3IVES FROM TO FT BELow SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS [IHO 171PIPE ❑ OOM CAP AT(>3 F ) FT BELOW SURFACE <br /> COMMENTS <br /> S WORKING DAYS NOTICEREQUIRED(AFTER PERMIT ISSUANC FOR INSPECTION APPOINTMENTS <br /> I hereby certify that i have prepared this, pplication and that the work will be done In sccorda �wlthSan Joaquin County Ordinances,Rules and <br /> Regulations,and II ppl Californ laws.Signed Title/Company ; 6f,41-daisr f D/14-, <br /> Print Name a4.,f 14.L- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE/SE DDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPT BY DATE ISSUED AREA <br /> GROUT INSPECTION FINAL INSPECTION BY DATE <br /> DESTRUCTION INNSECTION BY DATE <br /> COMMENTS/CO MONS: <br /> ACCOUNTI ONLY: AID* FAC III <br /> PE COD FEE INFO AMT REMITTED CHECK 0 RECV'D BY DATE SERVICE RO INVOICE <br /> REQUEST PR S <br /> 2 $122 X Baa - (l(� SRS -7 <br /> RO <br /> a50o <br /> zsoo <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 2401 07/26/10 WELL PERMIT APP <br />