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s / <br /> I I a 4 A<I NOACUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> L .11 1868 Hazelton Avenin, Stockton, CA 95205-6232 SITE MITIGATION <br /> ' j! I <br /> 1 7e hc��te:�209��€6 -3`147 Fax;{209} 468-3433 Web:WWw.sjgoV, rctlehd <br /> WELL A BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIAR11RONMENTAL HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ERMIT/SERVICE <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 <br /> •� t r c <br /> Department,ent. <br /> Site Location 1!+ - City/State <br /> f <br /> G' <br /> Str tC7r'e<� Ci /State 61 p 75-w& 1Y'7t77-APNPecperty wo Ci /State k pr Phone 2> , <br /> '4jLLOwner Address <br /> C-57 Contractor L6 ? 1 Address T a? 2 lu'r s I �7 c , <br /> a _ Ct JState L:4 z /le Lic l v r � Phone 7L <br /> Consultant/Sub Cntr r u7 z Address f-P-f- '14""-J�0CitytState �Ls".�a�Ljc Phone 2t <br /> Billable Party x:rVo, WS Address i lir I - Ui 'v City/State Zip Phone <br /> GIS Coordinates:X Y u <br /> CONSTRUCT RK TO BE PERFORMED; <br /> N 17VEt_ 13C}EdfF�C�{CPT.GEOPROSE•HYDROPUNCH,NAND-AUGER,OTHER) <br /> SOIL 't)Ft1fUG TDs s N t; Si <br /> Q WELL.IDs <br /> ❑OTHER IDs <br /> TYPE OF LLtBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING [I HOLLOWSTFIS DIA OF BOREHOLE Z f M El MUL IIPLE CASINGS 0 MULTI-LEVEL WELL C:ASII4G CSW: <br /> (�EXTRACTION:Vapor!Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: E)STEEL 0 PVC O OTHER <br /> _❑SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TPEMIE TYPE TO BE USED: O AUGERS O HOSE ❑PIPE <br /> l L SOIL ROPING `PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes ❑No(MAXIMUM FREE FALL DEPTH iS 30 FT) <br /> -.-_EI INJECTION(Le Air Snaroe oz-.r td HAND AUGER GROUT SPECIFICATIONS &0/co W k- JU•' <br /> _I]OTHER: ❑OTHER: APPROX BORING DEPTH g D BOLTED TRAFFIC BOX Of? ❑STOVE PIPE <br /> t. t <br /> COMMENTS: S <br /> CONDUCTOR CASING El No 11 Yes:Casing Dia: Casing Depth: Boring Dia <br /> ��'T'}c,' J� /.a.,rLl_':�,l,l�?'u( fA�"_' b'1'-ce'Tz~'r� i_�: ^C•r" v„r �-�sF•u-4�t <br /> NOTE, OFFSITE WELLS&SORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTIC}N WOf2K TO BE PE4'�FORMED: STRUCTION I�ETMOD;{CHECK ALL THAT APPLY <br /> #OF WELLO)TO BE DESTROYED ❑OVER-BORE DIAMETER OF ItdCHESTO DEPTH OF PT <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 <br /> COMMENTS [I MUSHROOM CAP AT(?3 FO_FT FT aELOW SURFACE <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 in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California laws, �j <br /> Signed r �Title/Company ff`jcx x16fr1jor1e_- 11/kcz t' fL ul <br /> Print Name c!'r�t� f" .7 r Date 1�0d t <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS i��� �, ����� {, -'7` <br /> WORK PLAN DATED C irz' <br /> APPLICATION ACCEPTED 13Y J, d AVC cor"t DATE ISSUED KY c AREA G ' <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# m <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE ROI INVOICE- REQUEST PR# <br /> 0 5�' $125. I as w,AG f °'W — <br /> '2 <br /> -- NO# <br /> _ (3500) <br /> - PR# <br /> - {2800} <br /> C-57-- <br /> 57 __._ WC _ _--WAIVER _a O--� C-57 LETTER OF AUTHORI TION TO SIGN PERMIT � L ENCROACHMENT DOC A <br /> E!{D 29-01 5109112 WELL.P E R M tT A PP <br /> 1I <br /> I <br />