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i <br />1 <br />,Qe�g�. oG SAN JOAQUIN COUNTY <br />-`" ENVIRONMENTAL HEALTH DEPARTMENT LOP <br />TION <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sigoV.org/ehd -_ <br />WELL & BORING PERMIT APPLICATION L-'1), aP iQ11 <br />FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1V"NVJ ()J\JMLN A'j_ f�Pl=,% �I-1 <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is mafiWiAtlhi}t�r>pgmri-"- <br />Joaquin County Development Titley C a er 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. <br />ler /- ski ���-s.ii�,e�i�P f �� 1� /� , <br />Site Location Cross Street City �� y Zip / s���7APN <br />Owner �n /kAl-r A�d!dreProe��� G d City J; �i� Zip I gd-O—Phon <br />C-57 Contractor l7! l �e ��aPdress SD (!F I -el) City Lic� S�4SPhon j?,/ d c6 <br />Consultant/SubCnt �L Address ���%� �'Py�:ity-���F��Lic6�Phone��(�� <br />Billable Party — Address / t% If/2EG i�n�Ci(y fT�IZ.Y�c�n/ Zip % Phon <br />GIS Coordinates: X._ Y _. <br />*NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) <br />SOIL BORING IDs <br />WELL IDs /Y! <br />❑ OTHER IDs <br />TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA:_ <br />_❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS C � if O TYPE OF CASING: ❑ STEEL VC ❑ OTHER <br />_❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL (0 TREMIE TYPE TO BE USED: AUGERS ❑ HOSE t] PIPE <br />_❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED.�M Yes ❑ No (MAXIMUM FR�EiEfALL DEPTH IS 30 M—[3 <br />INJECTION (i.e Air Some- ozone) ❑ HAND AUGER GROUT SPECIFICATION//S , C6;41rEltl�- <br />_❑ OTHER: ❑ OTHER: APPROX. BORING DEPTHSSS-I LTED TRAFFIC BOX OR STOVE PIPE <br />CONDUCTOR CASING ❑ No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: <br />COMMENTS: 1✓E� G G UZ/Yi�C/�✓ /t/G✓ 0 -- <br />NOTE: <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />' # OF WELL(S) TO BE DESTROYED <br />WELL IDs: <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED: AUGERS HOSE ❑ PIPE <br />COMMENTS <br />1 <br />1 <br />t <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />❑ OVER -BORE DIAMETER OF INCHES TO DEPTH OF FT <br />❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br />❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br />❑ MUSHROOM CAP AT (>3 FT) FT BELOW SURFACE <br />5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />I hereby certify that 1 have prepared this application and that the work will be done In accorinc with San Joaquin County Ordinances, Rules and <br />Regulations, and all applicable Californ ITIS. .i �/ 0 c -11112 - <br />Signed <br />lt1/LSignedli,__ "� Title/Company <br />Print Name L✓ ��CH �G �Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE SITE ADDRESS <br />WORK PLAN DATED <br />APPLICATION ACCEPTED BY <br />GROUT INSPECTION BY <br />4.- - DATE ISSUED AREA <br />FINAL INSPECTION BY <br />DESTRUCTION INSPECTION BY DATE <br />COMMENTS/CONDITIONS: 69' �/ l �tyy l: �•a�..• / �" tu�c t /` r (�� �11C -��� l� 1� f 7•—/` <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 />$125x <br />RO # <br />3500 <br />PR # <br />2900 <br />C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMEN F DUG <br />