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0¢4 Iy..•� • SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> �11,8�Ihi 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> Telephone: (209)468-3454 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> �/FORS <br /> WELL & BORING PERMIT APPLICATION F3ECEf `f D <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION f�� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' MAR 2 2 Ij 1 <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 Tide,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health <br /> �_����� q ftRtiMENTAt ,r g17N <br /> Site Location 44Ze35 W.W.vJ�}Cross Street N o,\I� -Dr. City <j�Zip /6206ERWTj',38* Aj Z iy502�7 <br /> Property <br /> Owner&b %rca, Oeerec CO AddressOm Vk&c-e. Citym01in21 IL Zip tat7- 5 Phone 244-773-?49 0 <br /> C-57 Contractor Address 31032 brnec Ccrr\2 city'AA>,etno CudooaLic'13%110 Phone I//(y-(a38--II& <br /> Consultant/Sub Cntr EQYy-1-VJ29'r Address 252r, rAdp,we F"V- or1�3 City SGCXor"en•4e Lic tJA Phone 911, YZ9-I37e <br /> Billable Party E2rv1- W e 5,1r, Address 2525 Nc kxws Pc,r L Dry 1'~360 City S%a &V✓ 40 Zip 9583� Phone`//a-YZ4- r3-7 <br /> $ <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLBORING(CPT,GEOPROBE,HYDROPUNCH, AND- OTHER) <br /> RRSOILBORINGIDs 5R-27 <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ,1 <br /> _❑MONITORING E]HOLLOW STEM DIA.OF BOREHOLE r [I MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: NA_I]EXTRACTION:Vapor/Water EIHAMMERIDRIVEN CASING THICKNESS r4A TYPE OF CASING: [I STEEL [j PVC [I OTHER NA <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL -TD REMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> Z"SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes XNo(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> INJECTION(i.e.Air Soame.OzoneIAHAND AUGER GROUT SPECIFICATIONSPnK.C W Ilt 6z gnAgA jla Tl A,-r Sa 1 IQ ColteJ-'010 <br /> OTHER: ❑OTHER: APPROX.BORING DEPTH —) rrw.x ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASINGXNo[IYes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLYI <br /> _#OF WELL(S)TO BE DESTROYED E]OVER-BOREDIAMETER 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 prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulation?,and all�applicable�CCaliiff�or�nia laws. <br /> Signed 'Y.:�. J Il ' luM�'-� Title/Company 1 C \Os\S� ' 1✓ I�r r 1 <br /> Print Name V-oyy�r- Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IVFILE- ITF ADDRESS W - Lll4 C V�'/"u Q' C—� �• - At:..t�-W <br /> WORK PLAN DATED / <br /> APPLICATION ACCEPTED BY L DATE ISSU 3 AREA 9 <br /> GROUT INSPECTION BY f�--�+' 'L FINAL INSPECTION BY Y DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM EN TSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> �--p Alec- <br /> y REa SSTT� /PR7# <br /> d— S� $ 122X �ZZ (21 L >O Alm" � 23 1 SR#6C-f 63 <br /> RO# <br /> 3500 <br /> a5 03 3s� jr,6 b r.,K 3 3 /i 2 00 6O <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 WELL PERMIT APP <br />