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1 oa� -ul`�• SAN JOAQUIN COUNTY <br />. •.o <br />y ENVIRONMENTAL HEALTH DEPARTMENT LOP <br />600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br />' Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.siaov.ora/ehd UNIT IV <br />���IFOta�`P <br />WELL & BORING PERMIT APPLICATION E� <br />FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIA RIECUj <br />' NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �,�1 >l <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 corp lari wi n <br />Jo ��I ty Velo m n Title, Chapter 9 1115.3, and the Standards of the San Joa ui County Environmental Health Department. <br />/vw�° iS77i9 ew�l Tr �/r�ee,�tt G � %.�� %S 37 U iNMEN i <br />Site Location <// Cross Street — O City y Zip jL <br />Property /%%6 ' ZR /ylL.� X!✓o/ {'/!!L/L%li�`� q5-' 1 -OS PpId <br />P" -7.p% <br />Owner��� 1 ,A/ddress q City Ip / Phon -J? <br />1 C-57 Contractor le -6; lole/Lz"AIfress 1$ �0 //we" City ��R�/�Ez ticl �s S Phon/ SOaL-> <br />Lf/6—A"-TIO LicPC 9Phon ltj'/ <br />��i �'//.?46 <br />ConsultanU O—O/�" Address 11f ��/P��R f7 �✓D/ 6 S2 <br />Billable Party Address_/d&/OCf/7'0924rZ✓Of✓City S%VZKTO�/�p 'S2v/ Phon Joj �y 306 <br />GIS Coordinate <br />C2NSTRUCTION WORK TO BE PERFORMED: <br />NEW WELLIBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) <br />0 SOIL BORING IDs I ' <br />RINELL IDs <br />OTHER IDs <br />TYPE & # OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS e� / !( <br />MONITORING P HOLLOW STEM DIA. OF BOREHOLE /d �� ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA, f <br />_❑ EXTRACTION: VapoN Water ❑ HAMMER/DRIVEN CASING THICKNESS eo TYPE OF CASING: ❑ STEEL�MPVC ❑ OTHER <br />_❑ SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL L TREMIE TYPE TO BE USED: AUGERS ❑HOSE ❑PIPE <br />_❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: j9Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />_❑ INJECTION (Le Air Soaras. Ozonel ❑ HAND AUGER GROUT SPECIFICATIONS <br />_❑ OTHER: 0 OTHER: APPROX. BORING DEPTH l�. BOLTED TRAFFIC BOX OR STOVE PIPE <br />/! CONDUCTOR CASING O No ❑ Yes: 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 APPLY) <br /># OF WELL(S) TO BE DESTROYED 0 OVER -BORE DIAMETER OF INCHES TO DEPTH OF FT <br />WELL IDs: 0 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br />GROUT SPECIFICATIONS 0 EXPLOSIVES FROM To FT BELOW SURFACE <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE 0 MUSHROOM CAP AT (>3 FT) FT BELOW SURFACE <br />COMMENTS <br />5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />1 hereby certify that I have prepare is application and that the work will be done in accordance with San Joaquin Coun O�nances, Rules and <br />Regulations, and all applicab if rnia Laws. 07? e/ <br />Signed Title/Company �� ✓�OfIQU/N Chi Y '"/��U"-rCl� ��_ <br />Print Name' /��L Date i/� <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE SITE ADDRESS <br />WORK PLAN DATED f�1 / -*� <br />APPLICATION ACCEPTED BY��/7 AREA <br />GROUT INSPECTION BY /9zf� Lim' i" f` FINAL INSPECTION BY"�'� «� "'BATE <br />DESTRUCTION INSPECTION BY DATE <br />COMMENTS/CONDITIONS-,vc�c +� �,��,./Cr.. �. e_'.s__._,:y` t f�1r_. r<c •-1 �y"• /1 <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 />SERVICERO <br />REQUEST/ <br /># <br />PR/# <br />INVOICE <br />I -1q % I <br />$ 125X <br />S R # <br />RO # <br />3500 <br />PR # <br />2900 <br />C-57 WC WAIVER C57 LETTER OF AUTHORIZATION 10 SIGN PERMIT ENCROACHMEN 1 DOC <br />