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SAN JOAQUIN COUNTY MAY s 6 joll <br />ENVIRONMENTAL HEALTH DEPARTMENT -. , , <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.s4ciov.org/ehd <br />LOP <br />SITE MITIGATION <br />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 DDev II ment Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. �� <br />Site Locatiop c `51 %%� Cross StreetS�, �if.� 1City /Mj0jZipJr.� APN '1 t/��/-7e/` <br />l <br />Property / <br />Owner Rid %y°�ir AddressQgl9�a_,cVV Rh,v City � A=o <br />ZipjPhone���L'-- <br />�1'i 7d'7rZ <br />C-57 Contractor j Address ImIr 11f/ %' ✓1.5 4-j Cityk2f1jolk FFR Lic!KCj3jLj Phondw-"Z9�5 0% <br />Consultant/Sub Cntr Address(& it&AbdKObi, City1Sjt2q& Wb&KLic Phonol€X�i-- T60- 77-77 <br />Billable Party Fi S Address LVC 16 W " Cityb/Aj (O0 WZipglz� PhoneTVT 1r0- -77%% <br />GIS Coordinates: X Y <br />C NSTRUCTION WORK TO BE PERFORMED: <br />NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, kjHER <br />❑ SOIL BORING IDs <br />❑ WELL IDs ISF-11R, 6 -.P at <br />r <br />❑ OTHER IDs <br />TYPE & # OF WELL/BORING INSTALLATION TYPE <br />_❑ MONITORING HOLLOW STEM <br />_❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN <br />_❑ SOIL VAPOR PROBE ❑ MUD ROTARY <br />_❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) <br />❑ INJECTION (i.e .Air Soarge. Ozonel ❑ HAND AUGER <br />OTHER: L.F6 BE ❑ OTHER: <br />Cd7'du1 :1:k191 <br />DIA. OF BOREHOLEgN ❑ MULTIPLE CASINGS KMULTI-LEVEL WELL CASING DIA: %e 31 r/ <br />CASING THICKNESS -IC# 10 TYPE OF CASING: ❑ STEEL 4PVC ❑ OTHER <br />DEPTH OF GROUT SEAL #_TREMIE TYPE TO BE USED: VAUGERS ❑ HOSE ❑ PIPE <br />GROUT SEAL PUMPED: ❑ Yesfi(No (MAXIMUM FREE FALL DEPTH IS 30 FT) y� <br />GROUT SPECIFICATIONS f4ja w AEAM WTIF" 1:;;&RI;- #kbAJr—L ti/rl <br />APPROX. BORING DEPTH iVP FT ❑ BOLTED TRAFFIC BOX OR STOVE PIPE <br />CONDUCTOR CASINGANo ❑ Yes: Casing Dia: Casing Depth: Boring Dia: <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (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 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 />Regulations, i <br />d t a IicabLe Californi4lawA. <br />`' I <br />Signed Title/Company Tp RGv•t�. <br />e <br />Print Name <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS <br />WORK PLAN DATED <br />APPLICATION ACCEPTED BY <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />COMMENTS/CONDITIONS: <br />DEPARTMENT USE ONLY <br />DATEISSUED <br />FINAL INSPECTION BY <br />DATE <br />AREA <br />DATE <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE <br />SERVICE <br />RO # <br />INVOICE <br />REQUEST <br />PR # <br />�� <br />s'Z.�o <br />$ 122 x <br />�% <br />SR# -OV <br />RO # <br />3500 <br />PR # <br />2900 <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 />