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1 <br />t <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />'ya <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.siaov.org/ehd <br />�/FOirl, <br />WELL & BORING PERMIT APPLICATION <br />LOP <br />SITE MITIGATION <br />UNIT IV <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 Development Title, Chapter 9-1115.3, and the Standards f theSanJoaquin County Environmental Health Department. <br />Site Location l� S� D Cross Street City ��0-14—" Zip / 5e77 APN <br />Property? X97 /%2 G lG dz.��ra� <br />Owner /_�� %R��� Address L Von CityV Zip Phon <br />C-57 Contractor er 4,e� «l�,�Address /���✓� �� city/'/ ��y�Ztit: �`�lKr Phon 3> 3 � ��d�7 <br />ConsuitandSub Cntr Z6 y C Address //�� �� �2�/ ,1�� S/yl' D/ tic �D Phon <br />Billable Party Address Za �f���"�City STyZxi O -✓Zip 9S� 0/ P <br />��hong/-2&iZ4 a✓ �.s' 0 6 L <br />GIS Coordinates: X f'' > � l 74, 1, <br />V WELLR30MNO (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) <br />❑ SOIL BORING IDs <br />(� WELL IDs G✓ —7 7 79 <br />(] OTHER IDs <br />TYPE & # OF WELUBORING <br />INSTALLATION TYPE <br />MONITORING <br />PIHOLLOW STEM <br />_❑ EXTRACTION: Vapor/ Water <br />❑ HAMMER/DRIVEN <br />_❑ SOIL VAPOR PROBE <br />❑ MUD ROTARY <br />_❑ SOIL BORING <br />❑ PUSH POINT (GPI CPT) <br />_❑ INJECTION (i.e ,Air Saame. Ozmal <br />❑ HAND AUGER <br />_❑ OTHER: <br />❑ OTHER: <br />GVNS 1 KUG 1 W nl SYGI:IFIGA I IClNS �� /� <br />DIA. OF BOREHOLE /bey/9MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: £9� <br />CASING THICKNESS S,a O TYPE OF CASING: ❑ STEELfi�,PVC ❑ OTHER <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:/%AUGERS ❑ HOSE ❑ PIPE <br />GROUT SEAL PUMPED:,V Yes ❑ No (MAXIMU FRE FALL DEPTH IS 30 FT) _ <br />GROUT SPECIFICATIONS r I E�� <br />APPROX. BORING DEPTH ❑ BOLTED TRAFFIC BOX OR PISTOVE PIPE <br />CONDUCTOR CASING ❑ 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 ❑ 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 0 PIPE ❑ MUSHROOM CAP AT L3 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 prepare is application and that the work will be done in accordance wi,San Joa uin Coynty O�dlna Rules and <br />Regulations, and ail ap licabl rnta Laws. SE/✓>U� C/t%/G ��� ��o <br />Signed Title/Company ��� `� d�ui�✓ Com`~ter ��� <br />Print Name :^� /Nl C/�A EG ��"1Zi21/L' Date ! <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE SITE ADDRESS <br />WORK PLAN DATED 111--112- <br />APPLICATION <br />/1--1/ Z <br />APPLICATION ACCEPTED BY DATE ISSUED AREA <br />GROUT INSPECTION BY f '^r J -y^7 . J"�+"� FINAL INSPECTION BY 7i -,DATE <br />DESTRUCTION INSPECTION BY p 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 />SERVICERO <br />REQUEST <br /># <br />PR # <br />INVOICE <br />tlY 7/ <br />ill 0 2 t j` <br />g 125 x <br />SRO <br />RO # <br />3500 <br />PR # <br />2900 <br />C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />