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6+Ctll5 S <br /> 4 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> " SITE MITIGATION <br /> ••.-- 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> Fop'•� Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.siciov.org/ehd <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 with San <br /> Joaquin County Development Title,Chapter 9-1115.3•and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location qCross Street "7 LIhCdV 1 City tale Zip Off. APN <br /> Property -� t V lxril-e G� / <br /> Owner G Address cu- I' City/Stale 1 p-J Phone G I)y7G C <br /> C-57 Contractor G (71 Address Cl /State tC �r Lic/ Phone Q�s �3 -� ) <br /> Tr�}r iF'�C yi�/S�a�e �Z �U ZIZOPhone�L�.29��S�SS <br /> Consultant/Sub Cntr l.(_�� Address <br /> Billable Party L A CS Address Ll I r City/State SC;W1�Se'_Zip Phoneyl$9q4-qS�95 <br /> GIS Coordinates:X 3 7. ` 4(3 Y -/I.( 3 o0( CA <br /> CO STRUCTION WORK TO BE PERFORM <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> 2110THER IDs L t IS <br /> r i <br /> TYPE&#OF WELL/BORING INSTALLATIOM TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING 0 wQLOSJ SM" DIA.OF BOREHOLE W <br /> ❑MULTIPLE CASINGS[I MULTI-LEVEL WELL CASING DIA: <br /> _O EXTRACTION:Vapor/Water ❑►�'�b% CASING THICKNESS 3 1 q TYPE OF CASING: ❑STEEL�[T`PVC E3 OTHER <br /> _2 SOIL VAPOR PROBE 0 uuu- ttA&- DEPTH OF GROUT SEAL El 5 TREMIE TYPE TO BE USED: AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POW(GPI CPT) GROUT SEAL PUMPED:❑.Yes • No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(I.e.Air Soame.Ozonel p�� nt a' 5'&5 GROUT SPECIFICATIONS k-1t 11 lrllt, <br /> _O OTHER: cOTHER APROX BORING DEPTH I U ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> C�11 h V C!!�L DOCTOR CASING eNo❑Yes:Casing Dia Casing Depth,- Boring Dia <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BOR!)M REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFOR-40 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: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑ANGERS C]PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE R>ECURED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this en and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all licabie Ca84orrda laps I" <br /> Signed Title/Company Olp '/ L S <br /> Print Name .i- Date Al"!t-' <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS tc� M <br /> OO 6), �(7ueell STRfE-r� Srwrm" <br /> WORK PLAN DATED �, zo 1 Im <br /> APPLICATION ACCEPTED BY A.�a.44'4 DATE IS /O`/64 AI A YG49 <br /> GROUT INSPECTION BY FINAL INSPECTION BY W 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 I PR# <br /> 110S $125. I Etft-r 2-7-/y SR# 51RcIc 4?0Z <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 WC P- WAIVER N/4- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _V ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />