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v SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> 600 East Main Street, Stockton,CA 95202-3029 SITE MMGATION <br /> Telephone:(269)468-3454 Fax,(209)468-3433 Web:vrww.siaov,:vretfehd UNIT fV <br /> f'.a <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR`CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appikadon Is hereby made to San Joaquin County for a permit to construct and/or Instal[the work described. This application is made in compliance with Sang <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location Ay 3 W6fer is b d cross street AIA12 &e. city. S4Dcktwn Z1p,S SQ o S APN 119 I q 0 3 8 <br /> Property <br /> owner AdAms 'IS-s2Dr City S*ckl-pn ZIp qui' -Phone ACq-937,957D <br /> c.57 Coninitaw P 0.80x Ys-S9 City�1r r ) <br /> Lie-73bo Phone 9 t6.QRo,0333 <br /> 1 r� V. <br /> Consuttant/Sub Crttr H(1) 14 <br /> An.S&) Address Ro, 13 1 Z,'55cl _ City n o jd2jt: 7306 Lie o 4( Phone 1 .6 3 <br /> wo <br /> BitParty Joe SGhao:F Address IP-a- Bac 7 3 30 City V Zip 3a <br /> , �„-Phone $bS•6�[�.f b 68 <br /> GIS Coordinates:X Y <br /> ED: <br /> NEW VIELLA110MG(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> O SOIL BORING IDs <br /> 0 WELL IDs <br /> O OTHER IDs <br /> TYPE&#OF WELL/BORING !WTALLpT ON TiLPE CtiOINS;MUCTIION SPECIFICATIONS <br /> `0 MONITORING O HOLLOW STEM DIA.OF BOREHOLE O MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _O EXTRACTION:Yapodf Water O HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL O PVC O OTHER <br /> _O SOIL VAPOR PROBE D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS 0 HOSE O PIPE <br /> _E3 SOIL BORING O PUSH POINT(GP/CPT) GROUT SEAL PUMPED:O Yes D No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION tie At 3mme.trrnnet 0 HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: 0 OTHER: APPROX.BORING DEPTH O BOLTED TRAFFIGBOX OR O STOVE PIPE <br /> CONDUCTOR CASING p No O Yes:Casing Dia: CasMg.D'"th: Boring Dia: <br /> COMMENTS., <br /> NATE: ®FF&ITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> 9&1Mjt9WN WOW TO 89 P P : DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELLS)TO BE DESTROYED ❑(AVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: It/- MW-Q. - - - -1 PRESSURE GROUT ToDEPTHOF 3 FT BELOW <br /> GROUT SPECIFICATI C O EXPLOSIVES FROM To ^—FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:Ll AUGERS IffHOSE O PIPE 0 MUSHROOM CAP AT L>3 FT) FT BELOW'SURFACE <br /> COMMENTS <br /> 5 W09IONG DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION.APPOINTMENTS <br /> I hereby car*that I hmm prepared this application and that the work Will be done:in accordance with San Joaquin County Ordinancas,Rules and <br /> Regulations, al pt Ie C tfornia Laws. ^� r <br /> Signed _ Tltlee/Company rf o? 1 DA S 6riYi( nID&T Gid I nG <br /> Print,NHO-( Date_ <br /> DEPARTMENT USES O LY <br /> SITE MAP IN UNIT IV jFILSITEADDRES$ C1�[iy'/&V �P S��WORK PLAN DATEDYAPPLICATIONACCEBY DATE ISSUED 2t� /L <br /> AREA. <br /> GROUT INSPECTION BY FINAL INSPECT.ON BY DATE <br /> DESTRUCTION INSPECTION BY DATL �1 1 T/ <br /> COMMENTSICONDITIONS, <br /> ACCOUNT[NG ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# SERVICE RO#_# RECV'Q BY DATE INVOICE <br /> REQUEST PR# <br /> � �c-c�$125 x 5- TdO r`k�/'� / SR# �tI �/0 <br /> S 7,5� �... ,� RO t'# <br /> 3500 <br /> PR# <br /> 2900 <br /> C67 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br /> ENCROACHMENT DOC <br />