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Regulatioms_and all appli e alifornia laws. <br />Signed <br />Print Name <br />Title/Company C-1 (0 <br />Pa te s(ka-1 It <br />C <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sjgov.orq/ehd <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 />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 />Site Location7)A-) .kirC, <br />Prope <br />Owners- k , .-- Sri.....-L.- Address 7 "1—P \ •,..1 • N•Z City Clr-•e-k 1-a..- Zipl .2;17 Phone 1_*1.- "1-1 C -10 24-C <br />C-57 Contractor LA so k....r..c--1- Address City J k I-. Lic 1 I owl-1 Phonei-D7-3 7-4 - '43 a D <br />Consultant/Sub Cntr ?--S Address ( 6 ,z-) c> City (.....1.A ......-- Lic Phone q 2- S. - GI'S V • I 61 o <br />Billable Party 4?-5. C..ab-c7 Address I, City r ( Zip Phone <br />GIS Coordinates: X Y <br />LOP <br />SITE MITIGATION <br />UNIT IV <br />Cross Street VI-1,3 ("1" City zip 1 (bi- 3 APN 1 12 o 4-02-C <br /> <br />CONSTRUCTION WORK TO BE PERFORMED: <br />O NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) <br />SOIL BORING IDs <br />DWELL IDs <br />OTHER IDs <br />TYPE & # OF WELL/BORING <br />1:1 MONITORING <br />0 EXTRACTION: Vapor/ Water <br />0 SOIL VAPOR PROBE <br />0 SOIL BORING <br />INSTALLATION TYPE <br />El HOLLOW STEM <br />0 HAMMER/DRIVEN <br />0 MUD ROTARY <br />0 PUSH POINT (GP/ CPT) <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED: 0 Yes 0 No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />0 INJECTION (i.e Air Soaroe, Ozone) 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: 0 OTHER: APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br />CONDUCTOR CASING 0 No 0 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 />4. # OF WELL(S) TO BE DESTROYED 0 OVER-BORE DIAMETER OF INCHES TO DEPTH OF Fr <br />WELL IDs:i.6.2--vtr,-os S. 21.?, b 7--S.'0VP, t'3 C CI PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br />GROUT SPECIFICATIONS )-•\ ,c--..,,k- C.-.,--.--•----1 0 EXPLOSIVES FROM TO FT BELOW SURFACE <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE jg PIPE .41MU,SHROOy CAP AT (3 FT) l <br />..i 1-e k ge c-..4..-e....... i- r 1 ,,r- s; FT BELOW SURFACE <br />COMMENTS Vre..--got .......e_ 2ce-k{:„.., 4- % A - . r 7 \ •... c_a_ -c a";'• os- <br />5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />I hereby certify that I have pre ared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE- TE DDRESS €94°( 4-0- kla ' <br />WORK PLAN DATED Sifq cr(/ <br />9,1 <br />APPLICATION ACCEPTED BY DATE ISSLJED <:)0 i l AREA <br />GROUT INSPECTION BY /4- FINAL INSPECTION BY id-- DATE <br />DESTRUCTION INSPECTION B_X DATE <br />61.., /k,.," .,;-(1 441 ittc4./ 4, Jok).-4 ,..i 1(z 'U4 tide , <br />COMMENTS/CONDITIONS: / i <br />ACCOUNTING ONLY: <br />t) 0 <br />AID # <br />u 0 c <br />FAC # <br />PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE <br />REQUEST <br />RO # <br />PR # INVOICE <br />251D2, $yz2)(b ?-i 6/6 1-4-- 51/1/3ett sR# 001,232.-1) <br />()fix-3 375 . 3 17 ,., RO # <br />(3500) <br />dA <br />PR # /25.1_7AOS7 <br />(2900) <br />C-57 WC WAIVER <br />EHD 29-01 07/28/10 <br /> <br />C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br /> <br />ENCROACHMENT DOG <br />WELL PERMIT APP <br />