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• SAN JOAQUIN COUNTY Is FILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> I LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> �iF• •R�P <br /> Telephone: (209) 468-3147 Fax:(209)468-3433 Web:v_Irvy —5Is1ov ora/ehd UNIT IV <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 Wth San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location/699 q< Ln Cross Street �iw.v:. <br /> Property - City/State7Y4--rtS ZiP.j533'Z APNQy 5-2-3 <br /> Owner. Os�t�,;..,..,(lir- //„_ =� Address 3non � Ci /State.5�^�...•_ <br /> v— ty Zip 94 R 3 Phone 9a5 7 <br /> C-57Contractor <br /> s! ���� <br /> Address3gQ4,� fj e a. Ci /State <br /> Consultant/Sub Cntr �� �' ty —LIo .2 o Phoneg-f6g- 79 <br /> �� ��� Addresso�ovr !L,-.c n� r City/State.Sr , Lic Phone�-t34� <br /> Billable Party_klga , 4/,/s Address 51;- Cit /State <br /> Y ZIP Phone .Si....` <br /> GIS Coordlnates:X 37 -,or.y Y-/ai. a459 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> WJ NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> 9 OTHER[ <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 7-2 MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL &tPVC ❑ OTHER <br /> _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: (]AUGERS 0 HOSE ❑PIPE <br /> _D SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes D No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _D INJECTION(1JL&-&AM2JQ&mP1❑HAND AUGER GROUT SPECIFICATIONS <br /> _O OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING❑No O Yes:Casing Dia: Casing Depth:__ Boring Dia: <br /> NOS E._OFfSLTEWELLSB <br /> BORINGS-REQUIREACCESSAGREEMENTS OR ENCROACHMENT.PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD rcHEc<ALL THAT APPLY,_#OF WELLS)TO BE DESTROYED ❑OV <br /> WELL IDs: ER-BORE DIAMETER of INCHES TO DEPTH OF FT GROUT SPECIFICATIONS ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> ❑ EXPLOSIVES FROM To <br /> TREMIE TYPE TO BE USED.❑AUGERS ❑ HOSE ❑PIPE ❑MUSHROOM CAP ar >3 FT FT BELOW SURFACE <br /> COMMENTS L ) FTSELOWSURFACE <br /> 6 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. <br /> Signed �nr, r /,/v a.. ��. �..� /� r Title/Company--Sr <br /> Print Name c_ /faN p GIS"— �— <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS /(,49 sze Lk �4 <br /> WORK PLAN DATED L CtCl 5 7- — 2013 <br /> APPLICATION ACCEPTED BY -i Do*-Kuru DATE S EA (��j C/ <br /> GROUT INSPECTION BY FINAL INSPECTION BY ..wrTE—^223 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> .29c�1 $125X ?5 r38Y> SR# f <br /> ago-� 321 P RO# <br /> 3500 <br /> PR# <br /> C-57 <br /> 2900 <br /> WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC" <br /> EHD 29-Ot /09/12 <br /> WELL PERMIT APP <br />