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a�Ii=aur'. <br />WELL & BORING PERMIT APPLICATION 1(.111 <br />FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT LOP <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 ��T -I A QN . <br />Telephone: (209) 4683454 Fax: (209) 468-3433 Web: www.siaov.ar�lleh I! 1` <br />lir Y.Il Il. <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EN141101NMi:N-IAf_I-EALI'I1 <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is madE'IFx abff laFid�l $an <br />Joaquin County Development Title, Chapter 9-1.115.3, and the Standards of the San Joaquin County Environmental Health Department. <br />Site Location ZZS5�-tir or w Cross Street �1'yt city k' VL_ zip9�J6-^ APN tl¢9-PSD�5 <br />Property (I0?;," it? �957,01- Phone 0 2.3OwnerQ a Address City ��l Zi <br />C-67 Contractor Re Address ,dP t s[ A_ city Lic S 5 Phone 4 3 ' 9355 <br />Address l� �(� §KtV L �f . City �O is Phone �� �� Dl t) <br />�ff�� �1IPS�..._ <br />Billable Party jll�etrtZ1- .10Z Address r759O tts'�VLIA'.tlkcity Bi JA✓' zips 0 2 9 Phonebo3)3 6 f <br />GIS Coordlnates: X r Y `I 7.t.�.{>'�� % �"� Pkv +ir a K � -AmL (L4 C_ - <br />Z-1 S OIb«{c C Z <br />,GEOPROBE,HYDROPUNCH,HAND•AUGER,OTHER) <br />.LWMONITORING t<HOLLOw STEM :DIA. OF BOREHOLE 10 ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br />_❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS th _TYPE OF CASING' ❑ STEEL. WPVC ❑ OTHER <br />_I "SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL �-�J' TREMIE TYPE TO BE USED: ❑ AUGERS XHOSE ❑ PIPE <br />MOIL BORING VA-F'DP�' ❑ PUSH POINT (GPI CPT) GROUT SEAL PUMPED: AY.e�,s,,❑I ,�'t'� <br />N�o (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />❑ INJECTION (i.e.AfrSoarn@. Ozone] ElHAND AUGER GROUT SPECIFICATIONS VV�[�Llf Ge' <br />_^❑ OTHER: ❑ OTHER: APPROX, BORING DEPTH b r 10OLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />%� CONDUCTOR CASING No C1 Yes: Casing D Casing Depth: Boring Dia: <br />J <br />COMMENTS: ��. �'�f : AA:A lT) %fit <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE�ACCESS A EEMENTS ORQ CROACHMENT PERMITS <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY) <br />71 # OF WELL(s) TO BE DESTROYED EFOVER-BORE DIAMETER OF IS NCHES TO DEPTH OF _FT <br />WELL IDs: — 1 ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br />GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM To FT BELOW SURFACE <br />TREMIE TYPE oG iA a <br />USED: ❑ A ERS_ �'H E PIPE �l _ USHROOM CAP AT L>3 FT) FT BELOW SURFACE <br />COMMENTS ItL( <br />RKING DA <br />1 hereby certify that I <br />Regulations,and il' <br />Signed —=/ <br />Print Name I <br />SITE MAP IN UNIT IV FILE SITE i <br />WORK PLAN DATED <br />APPLICATION ACCEPTED BY <br />GROUT INSPECTION BY . <br />DESTRUCTION INSPECTION BY <br />COMMENTSICONDITIONS: <br />PERMIT ISSUANCE) FOR INSPECTION APPOINTME <br />this application and that the work will be done In accordance with San Joaquin County Ordinances, Rules and <br />0 Z: Title/Company >Cfraiaj <br />I -- <br />SL,& . <br />DATE ISSUED A/ ('114017-- <br />FINAL <br />'1140c7' <br />FINAL INSPECTION BY <br />DATE <br />DATE <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 />I RO # <br />PR # <br />INVOICE <br />$7 <br />3 a� <br />�0�� <br />SR#004'4 _067 <br />(3500 <br />29 0) (Ia <br />r. -r7 %Air`. 1AIAIVFR C:57 1_ETTER OF AUTHORf7_Al ION 10 5fC3N PEKIvil1 tNC ROA(;t- MEN I DOG. <br />