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ie <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT LOP <br />2.. z <br />a O 12010 SITE MITIGATION <br />600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br />Te/e-3454 Fax: (209) 468-3433 Web: www.sigov-org/ehd <br />��FOR <br />,,E,MITISEAVICES MENTAL WELL & BORING PERMIT APPLICATION <br />PE�t <br />I-OR 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 of the San Joaquin County Environmental Health Department. <br />2I i�i 2�ti APNCity zip �xCross Street <br />Property ����3 <br />`� I <br />7Owne�OVeGmtw � Address IqS$'ACity �AZip Phone <br />City Lic 931 ,�- Phone �-3�6)C-57 Contractor Address yyUW <br />ConsultanVSub Cnttr `W- y -5 AddressbgQ-tj MW City vn LicPhone 'c <br />y`t'Billable Party �rU6 <br />Address (� 2 City ��/t D� Zip Phone <br />GIS Coordinates: X -i? l �l Li `td, 6` Y 5� L, s � <br />ANEW WELL/BORING (CPT, GEOPROPF HYDROPi wr1H <br />1ER) <br />❑ SOIL BORING IDs <br />PE CODES <br />FEE INFO <br />fir"Y'ELL IDs <br />yy\ W � <br />2 <br />L� OTHER IDs <br />�) <br />RO # <br />I PR # <br />TYPE & # OF WELL/BORING <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />MONITORING <br />JOLLOW STEM <br />DIA. OF BOREHOLE I1 l i El MULTIPLE CASINGS ❑ MULTI-LEVEL CASING DIA: <br />_❑ EXTRACTION: Vapor/ Water <br />[I\\HAMMER/DRIVEN <br />�WELL <br />CASING THICKNESS -� D TYPE OF CASING: ❑ STEEL 92/PVC ❑ OTHER <br />_❑ SOIL VAPOR PROBE <br />❑ MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />_❑ SOIL BORING <br />❑ PUSH POINT (GP/ CPT) <br />GROUT SEAL PUMPED: ❑ Yes ❑ No (MAXIMUM FREE FAL DEPTH IS 30 FT) <br />1 �U m VC; <br />_❑ INJECTION (i.e .Air Spa e. Ozone) <br />_❑ OTHER: <br />❑ HAND AUGER <br />El OTHER: <br />GROUT SPECIFICATIONS y�VY <br />// <br />APPROX. BORING DEPTH V' EI BOLTED TRAFFIC BOX OR R STOVE PIPE <br />CONDUCTOR CASING ❑ No ❑ 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 <br />Regulations, and al <br />Signed <br />Print Name Z7 - <br />have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br />California laws. <br />Title/Company <br />Date (i�3�'�/� Cry-I % <br />DEPARTMENT USE ONLY EC O <br />SITE MAP IN UNIT IV FILE - SI <br />WORK PLAN DATED /// <br />APPLICATION ACCEPTED BY <br />GROUT INSPECTION BY . <br />DESTRUCTION INSPECTION BY DATE <br />COMMENTS/CONDITIONS: rr)N%- /� �O. 7i+ J � �f%y - S d - 211V- L2 - 61r1l:Z - '7w'gbh <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 />I PR # <br />INVOICE <br />��7 ! <br />$122./10 <br />/ ZZ c/j) <br />SR#©d 15 S� <br />�o <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 />