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!" SAN JOAQUIN COUNTY COPY <br /> F ED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 ( NTT IM 2013 <br /> <rFb .a Telephone:(209)468-3147 Fax:(209)468-3433 Web:www.siciov.org/ehd <br /> WELL & BORING PERMIT APPLICATION RONMENTALHEALTH <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIA n ,ERMIT/SERVICES <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 <br /> Health Department. <br /> Site Location �I+ S. Ayyln-- 37-Cross Sheet :fiC4 t-9'ET City/State U"d:e,/u1` ,Zffp /✓W4"' APN r�7" 3e <br /> POwps %n 9 91141'. /Ylor-i-1 Address !i N�S Am.-z .SY-. Gdy/State�7Cc.Ek'i-zip /5 Z` ' Phone 2c�'r'`'f�3•(r/cL <br /> c-57co'ntractor" li6c T,- Aadraas s� rrrc�� �zati'.�°��I�� Ote 1 4ec11.z1 Uc 0 0 Pho.S'P-6.41-.3&rte <br /> ConsultanVSub CnttraLU "'c Address 37-SSI/I4,ISh1•-e/?ke_1 `�Chy/State Calk Phone 217-350 <br /> Billable Party�✓Vwv.z:iUrwS Address c,t Ola."��'� City/State Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCT N-WORK TO BE PERFORMED: <br /> EW WEL BUMN (CPT,GEOPRO@E,HYDROPUNCH,NAND-AUGER,OTHERI <br /> SOIL GIDS SR't -('YfYL"" •1 SQi i•; <br /> Q WELL IDs <br /> D OTHERIDs <br /> TYPE 8 It OF WELLBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ,_Q MONITORING O HOLLOW STEM DIA OF BOREHOLE Z if9 O MULTIPLE CASINGS O MULTHEVEL WELL CASING DIA: <br /> —O EXTRACTION:Va porl Water OHAMMER/ORNEN CASING THICKNESS TYPE OF CASING: 0STEEL 0PVC 0 OTHER <br /> _O SOIL VAPOR PROBE ```,,,.0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED. (]AUGERS O HOSE []PIPE <br /> SOIL BORING Tp PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION I'e Ah Saarae Does(O HAND AUGER GROUT SPECIFICATIONS �x'N'IO,lrjf slur <br /> _O OTHER: [I OTHER: APPROX.BORING DEPTH Zd FT O BOLTED TRAFFIC BOX OR OSTOVEPIPE <br /> CO DUCT�O No O YEs:Casing Dia: Casing Depth:_Boring Dia:_ <br /> COMMENTS: C.c n-'y %t ✓l <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OFWELL(S)TOBE DESTROYED ❑OVER-BORE DIAMETER OF NCHESTODEPTH <br /> OF FT <br /> WELL IDs: Q PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS 0EXPLOS WES FROM To Fr BELOWSURFACE <br /> TREMIETYPETOBE USED:El AUGERS 0 HOSE Ll PIPE Q MUSHROOM CAP AT(>3 FT) FT BELOWSURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done N accordance w(th San Joaquin County Ordinances,Rules and <br /> Regulations,a,n�d all applicable California laws. .— <br /> Signed _y, f+wr%l` Tide/Company_lRe)-)-,{,f if,L!g•- S-i✓ci1rJ„ j%iJl��✓JJ <br /> Print Name Data jC2/6//3 <br /> DEPARTMENT USE ONLY <br /> SITE MAPINUNIT IV FILE-SITE ADDRESS i�Y�, �J�Oe��S�rK�'y <br /> WORK PLAN DATED oCT� E(Z Zv f 3 a a <br /> APPLICATION ACCEPTED BYJ,�d 6'Ku0"t�'Ku0"t DATE ISS / <br /> GROUT INSPECTION BY FINAL INSPECTION <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITI ONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEEINFO AMTREMITTED CHECK RECV'D BY DATE SERVICE ROS INVOICE <br /> REQUEST PR# <br /> 11( <br /> . 01' $125x I LYJ 233�� CourvTbQ /W 3 SR# 68 3Jt <br /> RO# <br /> h L 3500 <br /> PR# <br /> 2900) <br /> C-57 ✓ WC // WAIVER 11/6- C-57 LETTER OFAUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC NAA <br /> EHD 29-01 5/09112 WELL PERMITAPP <br />