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TYPE & # OF WELL/BORING <br />MONITORING <br />El EXTRACTION Vapor/ Water <br />El SOIL VAPOR PROBE <br />n SOIL BORING <br />INSTALLATION TYPE <br />o HOLLOW STEM <br />ti HAMMER/DRIVEN <br />0 MUD ROTARY <br />0 PUSH POINT (GP/ CPT) <br />0 INJECTION UAL Air Searqe, Ozolig) 0 HAND AUGER <br />0 OTHER: 0 OTHER: <br />• <br />• <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3464 Fax: (209) 468-3433 Web: www.sjqov.orq/elici <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 Locationeacm <br />3 1 , L :?e• 171. iCross Street r41 - Dr. City Zip -'14;- APN 6 2- 03 c' <br />Owner k- t- <br />; <br />Address I t/je /1::/+., (1.- City 4, • • Zip -TC Phone r 0 1)T <br />Property,-,2 ( *, <br />C-57 Contractor T-"-5r Address 7 2-c• . <4 j city Lic L2b' Phonel eDV:KS - Zq <br />Consultant/Sub Cntr Address City Lb c Phone <br />Address 1( /Pt."' "V-44-ar• 'S k) City 1LA Zip/ Ceig Phone (q 14-0* Billable Party <br />GIS Coordinates: X '51 5-4 • 5 11. *-7 t_t <br />CONSTRUCTION WORK TO BE PERFORMED: <br />El NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) <br />El SOIL BORING IDs <br />0 WELL IDs <br />0 OTHER IDs <br />CONSTRUCTION SPECIFICATIONS <br />Dlk 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 D PIPE <br />GROUT SEAL PUMPED: 0 Yes 0 No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />GROUT SPECIFICATIONS <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br />CONDUCTOR CASING 0 No 10 Yes: Casing Dia: Casing Depth: Boring Dia: <br />COMMENTS <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />LOP <br />SITE MITIGATION <br />UNIT IV <br />DESTRUCTION WORK TO BE PERFORMED: <br />1# OF WELL(S) TO BE DESTROYED <br />WELL IDs: .1'1 . Vcq 35 T - 0 t. I 0 iP <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED: 0 AUGERS I=1 HOSE (21 PIPE <br />COMMENTS -7-r- e 4C •rt-to•-•-•r- 4-0: -1 4,- I <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />0 OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br />lErPRESSURE GROUT TO DEPTH OF F7 BELOW SURFAcE <br />C1 EXPLOSIVES FROM TO FT BELOW SURFACE <br />0 MUSHROOM CAP AT (?_3 FT) FT BELOW SURFACE <br />,4 tI A Lee <br />A <br />5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />Signed <br />Print Name s <br />pared 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 />I hereby certify that I have • <br />Regulatlo • all appl bl' <br />T---•5 Co rl <br />Date 4 ( f <br /> <br />DEPARTMENT USE ONLY <br />Li. IA-414 tA,f.C>tei* r'kleA.-- I Pe< I ;it", <br /> <br />SITE MAP IN UNIT IV Fir E - SITE ADDRESS <br /> <br />WORK PLAN DATED <br />APPLICATION ACCEPTED BY /44/CptAt- <br /> <br />DATE ISSUED <br /> <br />AREA qy 7 <br /> <br />GROUT INSPECTION BY FINAL INSPECTION BY <br />DESTRUCTION INSPECTION BY _____DATE <br />COMMENTS/CONDITIONS: CL)12-/A) C2 C-11 (Lea <br />ACCOUNTING ONLY: AID # FAC # <br />PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE <br />REQUEST <br />RO # <br />PR # INVOICE <br />$ 122x cr Plocil - \ 1 A.)-ic SR# CPO& Z-31b <br />!RO# .. <br />(3500) <br />(29ooV-1 <br />DATE <br />C-57 WC <br /> <br />WAIVER <br /> <br />C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />WELL PERMIT APP END 29-01 07/28/10 <br />