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SAN JOAQUIN COUNTY <br />a -crr �Z ENVIRONMENTAL HEALTH DEPARTMENT LOP <br />V.y` SITE MITIGATION <br />600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br />Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sigov.ora/ehd <br />WELL & BORING PERMIT APPLICATION RECEIVED <br />FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIA <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED jA'J 9 <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 comp iaMc 2 n <br />Jo i evelo m n Title, Chapter 9-1115.3, and the Standards of th San Joa u' County Environmental Health Department. <br />,S�� <br />EAR e�/y,�lL� x 8r✓off %R9Zi9S3'70NVI <br />NMENTA <br />LSite Location S!/E Cross Street City p <br />Property/d76 <br />Owner%JP9 Address CityS114✓ViIpAr�oSPhoni <br />�-� <br />C-57 Contractor /9b4 ,Ole/L'0',A/(ess q S0 /6.9Ph% <br />3-� s.0vU <br />Lo /f Lic6�Phon �/ <br />��� '�^' <br />Consultant/ Address �����%'� ��R� S��.D/6VO 6 S2 <br />Billable Party S ,%Oi4�. Address 1d'10 ef /P .?e4 9111"City 0 ,:� 6 <br />i6 � i.nif tirt� <br />GIS Coordinates: X — Y ' `" <br />e <br />Q(/NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) <br />% ❑ SOIL BORING IDs <br />RVELL IDs -od fAr✓_ offt ' <br />OTHER IDs <br />TYPE & # OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE /d ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA., <br />_❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS Soft ed TYPE OF CASING: ❑ STEEL VPVC ❑ OTHER <br />_❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL 4 TREMIE TYPE TO BE USED: rIkAUGERS [IHOSE ❑ PIPE <br />_❑ SOIL BORING [IPUSH POINT (GP/ CPT) GROUT SEAL PUMPED: 39Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />_❑ INJECTION (i.e.AirSoarae. Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS <br />_❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH BOLTED TRAFFIC BOX OR STOVE PIPE <br />,!Eu _ CONDUCTOR CASING ❑ No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: <br />COMMENTS: �(�L/�}//0!� /✓✓�'i ��✓,pic�GL�L'G <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 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 with San Joaquin Coun Or ances, Rules and <br />Regulations, and all applicab ifornia Laws. ,SAH/O'j2 <br />Signed ATitle/Company ✓���Ru/N C �' N� i� 'P�V --tom ��_ <br />Print Name 1047 ZWi A94 L Date ice. <br />SITE MAP IN UNIT IV FILE SIT <br />WORK PLAN DATED V ' <br />APPLICATION ACCEPTED BY <br />GROUT INSPECTION BY <br />DEPARTMENT USE ONLY <br />AREA / <br />t)ATF 3 �� `1A 2— <br />DESTRUCTION <br />DESTRUCTION INSPECTION BY 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 />SERVICE <br />I RO # <br />INVOICE <br />REQUEST <br />PIR # <br />Yq7 r <br />$125x <br />SR# ik Z1 <br />RO # <br />3500 <br />PR # <br />2900 <br />C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />