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iURIUMML <br /> �O9'�'u tN••C SAN JOAQUIN COUNTY <br /> Q ENVIRONMENTAL HEALTH DEPARTMENT RE <br /> SITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> • � P� Telephone:(209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.orq/ehMAx-2 8 WRIV <br /> _ <br /> q ••.....:.'� <br /> ��IppR� <br /> WELL & BORING PERMIT APPLICATION NTALHMTH <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND RENfI�� ERVICES <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 /> J�gtui�unty Devglopment Title,Chapter 9-1115.3.and the Standards of the San Joaquin County Environmental Health Department. /��-�c�t r <br /> Lt <br /> Site Location(a�C, tk &✓ I Cross Street �1J�> City/State�"t°rZip� � APN V!��' <br /> Propert <br /> Owner (� Address tt �Q udr- City/StatelXU�Zip q\ Phone��!& -1282 <br /> C-57 Contractor p1ddres City/State Lic `2�eSjj.D_ Phone - <br /> Consultant/Sub Cntr D Addi city/State Lic Phone(?/&,9A?- MIt <br /> Billable Party I dress OC1ty/State0Xj Zip Phone CY& 80-$1ls <br /> GIS Coordinates:X Y <br /> 37,q57 -t D <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑ SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED: ❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i e Air Sparge Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> =#—OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: MW—W-' 1 ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFAC E <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I hav ared this application and that the work will be done in accordance with San Joaquiin,County <br /> .Ordinances, Rules and <br /> Regulations, a alifornia laws. <br /> p c < �X! <br /> Signed Title/Company <br /> Print NameMmkAWVADate <br /> DEPARTMENT USE ONLY�-fin -/ <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 67,U 0, ()f/f1R7,Zl - 00"A, <br /> WORK PLAN DATED t Q)I, & ED 114 <br /> APPLICATION ACCEPTED BY �4n Kµ� DATE Icall I <br /> EA <br /> mc. <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <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 /> 50 $ 125 x /b7 4( C",a.v?Ee- S-zs-/q SR# (.Q80? <br /> U RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 WC /-' WAIVER___&,jj 2-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 WELL PER P <br />