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1 <br /> E <br /> SAN JOAQUIN COUNTY <br /> LOP <br /> ENVIRONMENTAL HEALTH DEPARTMENT TION <br /> 600 East Main Street, Stockton, CA 95202-3029 E I <br /> Telephone:(209)468-3454 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> trFOR� <br /> WELL & BORING PERMIT APPLICATION DEC 2 12010 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTALN <br /> Applicatic)c is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application ismEadeMATei>rSqi San <br /> Joaquin County Deveiopmenl Title,Chapter 9.1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location �r C _ Cross Street t-- City !Zac4 Zip Ziac G APN 00!_ <br /> Property `� <br /> Owner..0 �y_( I�(ftiv j �ron Address :1—U11�aS ittc��eC�a m City 16`,44__Zip 9S�id3 Phone <br /> C-57 Contractor sz �J Address g ! _ __ City (�sdr+idN L}c NSSIGS Phone ('1.193i3a <br /> 3v <br /> Consultant/Sub Cntr MG Address Q�� � City�o9wi Lic Phone <br /> Billable Party 17 ic.«s)Address Law. -i < _!� v! City Zip Phone___ <br /> GIS Coordinates:X_— Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> J NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> O SOIL-BORING IDs 4 <br /> El WELL IDs — <br /> ❑OTHER IDS — <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ^E MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE El MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _ <br /> v❑EXTRACTION:Vapod Water ❑HAMMER/DRIVEN CASING THICKNESS _ — TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> __❑SOIL VAPOR PROBE G MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS C HOSE ❑PIPE <br /> ^❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> I _❑INJECTION ie grsaaroe.Czon.)❑NANDAUGERGROUT SPECIFICATIONS <br /> __❑OTHER: El 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: <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 WELLS TO 8E DES ROYED OVER-SORE DIAMETER OF.�_NCHES TO DEPTH OF 67- 'FT <br /> tNELL IDs TO PRESSURE GROUT TO DEPTH or FT BELOW SURFACE <br /> GROUT SPECIFICATIONS L]EXPLOSIVES FROM ro > r eELow srra Ace <br /> TREMtE TYPE TO BE USED:YZIAUGEIRS ❑HOSE El PIPE O MUSHROOM CAP AT L3 FT} FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING [JAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have p pared t ' application and that the work will be done_/<accu dance with San Joaquin County Ordinances, Rules and <br /> Regulations n n' aws. <br /> Signed TitletCompany1� _��"��A�¢ —` <br /> Print Name Date _ <br /> DEPARTMENT USE ONLY FILE CUPY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PIAN DATED /V <br /> APPLICATION ACCEPTED BY I ��t CA DATE ISSUED 1 2 7-1 ) AREA <br /> GROUT INSPECTION BY �y nn�c-1. FINAL INSPECTION BY jA_c��— DATE�� <br /> DESTRUCTION INSPECTION BY DATE <br /> I <br /> COMMENTS/CONDITSONS: <br /> ACCOUNTING ONLY: AID# FAG# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> j REQUEST1 !!PR# <br /> 3SV2_ $122x 3b6.va < ►z. 2r (U SR# (0 T' <br /> RO# <br /> 35-03, 3 6.C7C� 3500 l7 SZ <br /> PR# <br /> j C-57 f WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACE iMENT DOC <br /> EHD 29 07126110 WELL PERMIT APP <br />