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SAN JOAQUIN COUNTYV�p <br />Mq y 2 <br />ENVIRONMENTAL HEALTH DEPARTMENT6 <br />,, <br />600 East Main Street, Stockton, CA 95202-30291rf'c <br />Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.siaov.ordkshd <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 ment Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. <br />Site Location Cross Street S�f�G/t84e rX)> , City � i� T Zip APN ilD�t�©� <br />Property <br />Ownera(a% f wPi Addressq 9S ' fq5 A r City Zip Phone�Otn—�S%`` <br />rr�fa— <br />C-57 Contractor jG Addressi-W � �✓M bR , CityjY�f'flOA1S &tR Lic` 3� 4 Phone <br />�d 9,+s fir/ <br />Consultant/Sub Cntr j Addressl746:7 %il �i�-Citybi/ y6J�� Lic Phon r; 1227 <br />—7777 <br />Billable PartyB Address 'y��,(57A.bR. City,A> ip!Z�PhoneYf irt;�7-7 77 <br />GIS Coordinates: X Y <br />C STRUCTION WORK TO BE PERFORMED: <br />EW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,Hf ER� <br />❑ SOIL BORING IDs <br />❑ WELL IDs <br />❑ OTHER IDs <br />TYPE & # OF WELLIBORING <br />❑ MONITORING <br />❑ EXTRACTION: Vapor/ Water <br />❑ SOIL VAPOR PROBE <br />❑ SOIL BORING <br />INSTALLATION TYPE <br />p�OLLOW STEM <br />/❑ HAMMER/DRIVEN <br />❑ MUD ROTARY <br />❑ PUSH POINT (GP/ CPT) <br />_❑ INJECTION (i.e .Air Soarae. Ozone) ❑ HAND AUGER <br />OTHER: L r-6 1I ROE ❑ OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />I�//'' if 3 <br />DIA. OF BOREHOL fL�V'❑ MULTIPLE CASINGS,&ULTI-LEVEL WELL CASING DIA:Yl, <br />CASING THICKNESS,'Cg'&i 1W TYPE OF CASING: ❑ STEEL,)E!�PVC ❑ OTHER <br />DEPTH OF GROUT SEAL Y FT TREMIE TYPE TO BE USED,�FfAUGERS ❑ HOSE ❑ PIPE <br />GROUT SEAL PUMPED: ❑ Yes,2�No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />GROUT SPECIFICATIONS �FX}jMTr— Ce&t�5— jjj tj&� <br />APPROX. BORING DEPTH (� �`� ❑ BOLTED TRAFFIC BOX OR,)6TOVE PIPE <br />CONDUCTOR CASING ❑ NAYes: 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, g46Appfic4kAXalifornia IjfWsa , <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 />Title/Company <br />DEPARTMENT USE ONLY <br />DATE ISSUED AREA <br />��� <br />FINAL INSPECTION BY DATE <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 />REQUEST <br />RO # <br />PR # <br />INVOICE <br />$122x <br />�(/� <br />\� f�� <br />,� <br />SR# 006-Ljv/'? <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 />