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c <br />SAN J QUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPART �',,.r�'�1 SITE M TOIGATION <br />r <br />600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br />Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: WWW.SIg0V.OVig/ehd <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�� pment Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. / <br />Site Location o . Cross Streets ©i ( . City H/�h'�� Zip 16 APN `ICK�p <br />Propert I <br />t�� <br />Owner (%r2i✓�+ah fit%�✓> Address nn y4u,�-77�fJ lu>. City tjA4y�l� Zip!=? Phond%W- —':?0k&'6f�L_ <br />C-57 Contractor Addressti Y �r{dS/"�i Cityb W Lic EJE33 Phone4s;2,115— T l J <br />Consultant/Sub Cntr F'77 Address 131.P �� i1(S�? i City AAA Lic Phone Tc—!%—U0-7777 <br />Billable Party ,?&� Address CityjV&&0,W ZifJq� Phon&&! -13jr,0"r_77.77 <br />GIS Coordinates: X Y <br />C12NSTRUCTION WORK TO BE PERFORMED: <br />EW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER T�' <br />❑ SOIL BORING IDs <br />❑ WELL IDs j::FP— <br />❑ OTHER IDs <br />TYPE & # OF WELL/BORING <br />INSTALLATION TYPE <br />_❑ MONITORING <br />HOLLOW STEM <br />_❑ EXTRACTION: Vapor/ Water <br />❑ HAMMER/DRIVEN <br />_❑ SOIL VAPOR PROBE <br />❑ MUD ROTARY <br />❑ SOIL BORING <br />❑ PUSH POINT (GP/ CPT) <br />_❑ INJECTION (i.e.AirSoarge Ozone) ❑ HAND AUGER <br />_OTHER:1_F6'FjRaRE ❑ OTHER: <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLEt�ne ❑ MULTIPLE CASINGSidMULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS_'n# 4&(% TYPE OF CASING: ❑ STEEL,26VC ❑ OTHER <br />DEPTH OF GROUT SEAL ?e FV TREMIE TYPE TO BE USED:,.AUGERS ❑ HOSE ❑ PIPE <br />GROUT SEAL PUMPED: ❑ YesKNo (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />GROUT SPECIFICATIONS HFI,�F MIM ff �R/I�Tf7� <br />y <br />APPROX. BORING DEPTH ��r, ❑ BOLTED TRAFFIC BOX 011)1�STOVE PIPE <br />CONDUCTOR CASING)4- ❑ 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, d ca ornia ' w <br />Signed _ ,G Title/Company Aal. <br />Print Name ��fL �y Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS <br />WORK PLAN DATED <br />APPLICATION ACCEPTED BY DATE ISSUED AREA <br />GROUT INSPECTION BY FINAL INSPECTION BY Vz DATE <br />DESTRUCTION INSPECTION BY DATE <br />COMMENTS/CONDITIONS: <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 />N4774 <br />$ 122. <br />� %?/ — <br />yy � o <br />n n <br />N (1' <br />S I <br />SR# 00 644' /? <br />- <br />RO # <br />3500 <br />T_ <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 />