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SAN _ : OUNTY-WELL-PERMI&PLVAN JOAQUIN COUN 1 YP:"w*cehd.com/doc 1�> L. <br /> K ENv Y IRONMENTAL HEALTH DEPARTIv,cNT P <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 S!. _GATI ._ <br /> P•• ``.UN�-r ly.. <br /> <)Fo Telephone:(209) 468-3147 Fax:(209) 468-3433 Web:wwwsiaov.ora/ehd - _ M�7-- <br /> WELL & BORING PERMIT APPLICATION MAR 14 ��13 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH <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 cortip!iabirTeI1N161 0,6 <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location No W. "L 144110-WAY Cross Street -'(ILLI(, LVV-s, 71RIJt0City/State T1L -4CAZip 95266 APN 163 -0ZO-'(! <br /> Property 5a <br /> Owner Foc�t�SyAITH -(,SNI Address 5(1 Lai.F'uwt1 .$T�`L'�Iry/State LAST T�p-7$Z`ir-{ phone 77 6A1-75{6 <br /> C-57Contractor WOCdtu4Atyl.4 G Address5.50 RtVA-k 2.6,Wk33(e City/State A6UWTk,Gdr Lic -716019 Phone 07 -3'N-4300 <br /> Consultant/Sub Cntr-1118 5ov a kg( �P Address 347V5,35 R A%6, 5h>.ivo City/State R'W'1(p1.i 7510 3 Phone &A 10-U56 <br /> Billable Party 199 &Orct G4,9 Addresi VVxe4 c IWISTaico City/State Fit N,w AZip L52 Phone cy y'J 7$55 <br /> GIS Coordinates:X Y <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 OFCASING: ❑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(Ie.AIr scams Omnel❑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: pESTRucnoN METHOD•(CHECK ALL THAT APPLY) <br /> /A #OFWELL(S)TOBE DESTROYED ®-OVER-BORE DIAMETER OF 16 NCHESTODEPTHOFTo��PIH'IFT <br /> WELL IDs: n+w-5hnW-y w'J-l9 ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS_PiZ, TLM 01 IRrWTO-A4P'F ❑EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:g}AUGERS ❑HOSE [tPIPE ❑MUSHROOM CAP AT!Z3 Fr) FT BELOW SURFACE <br /> COMMENTS GP.CJT To 3-a'Fh5 Its -AK CeWLic-B <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify t I have prepar this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, nd�a i a Iicable ifornia laws. <br /> Signed Title/Company 600c,06,s-r rSyiecd 62c./P, /Mc- <br /> Pdnt Name Date 3A /J3 <br /> G DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS / 7 001 (,J I (1hWj2yz-je bLQtj <br /> WORK PLAN DATED_ A1006u01 BER 20 1 ZO/ 3 <br /> APPLICATION ACCEPTED BY _�. J vY�KN w. DATE ISSUED 3.19'/3 AREA /6,Tf <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 PRO# INVOICE <br /> REQUEST PR# <br /> s tzs X 3 5 3GG ¢0(4WrEa 3-1N-1 SR# (.671 <br /> A -15 3Ro# <br /> 3500 <br /> oft PR# 3111131241P <br /> ZsoD) <br /> C-57 f/ WC t-� WAIVER Al C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> FHn Pp-n1 fini9 WFII PFRMRA P <br />