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SAN .10AQcfr%r Eli Irm--p-b. <br /> UIN COUNTY V-swe ORIGINAL ' <br /> r' ?' ENVIRONMENTAL HEALTH DEPARTMENTMdVCLJ <br /> <'I <br /> .: 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> y MawMl lI <br /> Telephone:(209) 468-3147 Fax.' (209) 468-3433 Web:www.sichv.org/ehd �,-r— <br /> CIFOR.� <br /> WELL & BORING PERMIT APPLICATION ENVIRONMENTAL HEALTH <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIApL*}gMIT/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 Health Department. <br /> vr1 <br /> Site Location Cross Street �"Qk l INAN-1 City/State Zip _ APN jt,tjT--byy—h . <br /> Property3 <br /> Owner ��—�n \l Address 3y City/State CQM iij ' Phone 7.� <br /> C-57 Contractor s A dres j�D DUALt-IK City/State c L2�110 Phone 1 -3 43 <br /> % 4. <br /> Consultant/Su n r v Ad / ity/State LIC 3%? r <br /> Billable Party Address NJ ity/State lea Zip M170 Phone <br /> GIS Coordinates:X 32-232t(, Y '121. A9S'<1 <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 WELLIBORING 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 Soame.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 /> D STRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY ��j <br /> #OF WELLS TO BE DESTROYED + fy—al OVER-BORE DIAMETER OF INCHES TO DEPTH OF—FT <br /> "�FT <br /> WELL IDs:�-SQj M W-t X3101 �,� PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> 5� 9� GREOMIE TP PCIFICATIONS AUG RS [—] HOSE E] PIPE MUS ROOM CAP AT(>3 FT)'�-EXPLOSIVES FROM To FT BELOW SURFACE <br /> BELOW SURFACE <br /> gQMMEbI LS-3 <br /> 5-y�(M1ORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS weckuw <br /> jf 0hereby cert' h t \aveRethis application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,an aprnia laws. <br /> Signed Title/Company fmlymwulkkk <br /> Print Name Date <br /> //-- DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS t P� 1J `^IYARTE //]A�, SI�KTV hJ <br /> WORK PLAN DATED /7 f 2« 1 / <br /> APPLICATION ACCEPTED BY r (, yp�}.ru N'i DATE IS SUP W4�4 Aft,19 <br /> GROUT INSPECTION BY FINAL INSPECTION BY j V4 44 01 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 I RO# INVOICE <br /> REQUEST I PR# <br /> 950z $ 125 x ecxcu, 5-� , SR# <br /> 350 3 7 R5oo <br /> PR# <br /> 2900 <br /> C-57 WC r/ WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />