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Aqutry SAN JOAQUIN COUNTY <br />LOP <br />.` ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION <br />600 East Main Street, Stockton, CA 95202-3029 1 <br />• �q. • Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www,sigov.oralehd <br />tFkoR� <br />WELL & BORING PERMIT APPLICATION MAY 2011 <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 119yiAlskWALTH <br />Joaquin County Development Title�hapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. <SE CES <br />/I/dR%N`G✓�ST SlpE �7� •— <br />�SO p �371APN�3' <br />O ?C" SiteLocaao� CityZ <br />Property <br />a LP z lklo%ye /�GlOwers" l to <br />�.S�.J Phone %o} �� <br />— C-57 Contractor <br />Address <br />City Lic Phone <br />Consultant(Sub Cntr Address 2 r� City -- Lic Phone <br />. Billable Party r -d Lnj dress 5 E C,l<� Y-fCity E0&(__ Zip _ Phone `7 / <br />GES Coordinates: X Y <br />GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) <br />❑ SOIL BORING IDs <br />❑ WELL IDs -------- <br />El OTHER IDs <br />TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />_❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE ❑ MvLTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br />EXTRACTION: Vapor/4ftter [IHAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL PVC -'r OTHER -!7- <br />_0 SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL.4 F/ TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />_❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes ❑ No (MAXIMUM FREIE ALL DEF_TH IS 30 FT) <br />_❑ INJECTION ke.AirSotroe.Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS <br />_ ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 3 Z E-1 ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />® NDUCTO SING ❑ No ❑ Ye -Casing is: Casing Depth: Boring Dia: <br />COMMENTS: 1A1S,7A`t1A-i1; U/- AZA t 6� Exi" iw��G� <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT- PERMITS <br /># OF WELLS) TO BE DESTROYED <br />WELL IDs: <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />COMMENTS <br />®1111, <br />5 WORKING DAYS NOTIC 1RED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />I hereby certify that 1 have preps a icatio and that the work will be done in accordance with San J aquin County Ordinances, Rules and <br />Regulations, and I applicable 01 <br />is 1 <br />Signed Title/Company y <br />Print Name _ 1, J D.4e�� <br />❑ OVER -BORE DIAMETER OF INCHES TO DEPTH OF FT <br />❑ PRESSURE GROUT TO DEPTH OF IFT BELOW SURFACE <br />❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br />❑ MUSHROOM CAP AT (>3 FT) FT BELOW SURFACE <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 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 />REQUEST <br />RO # <br />PR # <br />INVOICE <br />$122x <br />SR# <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 />