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. • SAN .IOAQUIN COUNTY E COPY <br /> 10. .co <br /> r. " :z ENVIRONMENTAL HEALTH DEPARTMENT <br /> a < <br /> � 1868 Hazelton Avenue, Stockton, CA 95205-6232 �,p <br /> Telephone:(209) 468-3147 Fax:(209) 468-3433 Web:www.siaov.ora/ehd "v �EW4— <br /> �rFORN <br /> WELL & BORING PERMIT APPLICATION �p�tpq� <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEvrvtlu{gNMENTAL HEALTH <br /> hIAMIT/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 DDevreeI0gnerO,Title,Ch ter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> drt TT ''11 CC okerNua 1� <br /> Site Location t//'>?�r.ft LT�1 Cross Street cart-.) f iojtow fZQ city/state 77- Zip 4 5 37l APN <br /> Property <br /> Owner a Address 3 'L �;.,t ro/C�/City/State Zip 95 Phone <br /> 3Zl�-$ 31-600 <br /> C-57 Contractor V 'V� r. Address VOG b,.,LCreek Dr. City/State Zip <br /> 72090V Phone Zy$- 4/L9-7>e� <br /> ConsultantlSub CnlrIQrtin Pt l�.�f Address 3077 �•}. . City/State en. Lic Phonegfd'3AIS�-f7o7 <br /> Billable Party I�C((.n�(oQ e/ Address 30» F:�t C7i ifr City/State 5Lce_ ,Zip 95'3!2) Phone 9fG- 3Gti -/>of <br /> GIS Coordinates:X 37.4 Q o2-4 Y -121.4 A2 I <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> @SOIL BORING IDs B— f 113— Zi 8�3 y Q^w <br /> Lj WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _[I �pr�MONITORING �y,OLLOW STEM DIA.OF BOREHOLE Sii D MULTIPLE CASINGS[IMULTI-LEVELWELL CASING DIA: <br /> _D EXTRACTION:Vapor/Water D HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER <br /> _D SOIL VAPOR PROBE D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS D HOSE IN PIPE <br /> f DKSOIL BORING D PUSH POINT(GP/CPT) GROUT SEAL PUMPED:&Yes D No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _D INJECTION(.e Air Soarae.Ozwt)D HAND AUGER GROUT SPECIFICATIONS rel.(w I-- <br /> _D OTHER: [3 OTHER: APPROX.BORING DEPTH ( x0_// D BOLTED TRAFFIC BOX OR D STOVE PIPE <br /> CONDUCTOR CASING D No D 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: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <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 have pre ared hi application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all applic al'f r a laws. 01 I(o 310 <br /> Signed. Title/Company <br /> Print Name - Date y - <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS Z 9�{cj �� �2Q,3s. I�oAcacJ R� , T219c�N <br /> WORK PLAN DATED E R RRI /q c <br /> APPLICATION ACCEPTED BY J• /p 6*kyN? DATE AREA 167 <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 PRg# <br /> O S <br /> $ 125, 1 �.L)<1 6qC.oc.afr'EQ ``�-I`{'I y SR# 6%58 <br /> 5U <br /> RO# <br /> 24� J 37s 3508 <br /> PR# <br /> 2900) <br /> C-57 y WCy WAIVER A/"-- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ` ENCROACHMENT DOC A/,A <br /> EHD29-01 5/09/12 WELL PERM) APP <br />