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SAN JOAQUINCOUNTY- WELL-PERMIT-APPL.pdf http://www.sjgov.org/ehd/docs/V;ELL2E�I�N�if L.pdf t 'o..!'a�'I'y c\ 1✓ SAN JOAQUIN COUNTY �J O R 1 G N �1 �. —E�•.o VENVIRONMENTAL HEALTH DEPARTMENT LOP H 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION .. ;p Telephone: (209)468-3454 Fax:(209) 468-3433 Web:www.smqov.org/e UNIT IV WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIOI'AR 15 2013 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application i e uz,Cth_ n Joaquin County Development Title, Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Dep t'�I L �-�L7H 1 r�Er�vilT/ate �c' Site Location Jay ! F I/s�/lC rL Goss Street tti S�i'CC 1 City /3,2A�a Zip �1s3 v APN 7- Pro5 2"� Owner Te ery Moor— Address PV 13 ox &7 City 136v'1.rA- Zip 9S3d Phone�zog��3S Z 7sa C-57 ContractorW IW Dr%/1,n5 /Address 3$r/Co J�+.rkClcck Dr City 5lncktr�n Lic 72o9oY Phone Czo9)y7s-gyvo Consultant/Sub Cntr APf-X FX7y '"Address //Zqt(Pinks w4-i City Cao/d R4A4 Lic Phone Billable Party Address City Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAN D-AUGER,OTHER) ❑SOIL BORING IDS ❑W ELL I Ds ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑MONITORING ❑HOLLOW STEM DiA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA- —[]EXTRACTION Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING. ❑STEEL ❑PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED ❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) —0 INJECTION G-e_Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER ❑OTHER. APPROX BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes Casing Dia: Casing Depth Boring Dia- COMMENTS_ NOTE: OFFSITE WELLS 8r BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS �DE?STRUCTION WORK TO BE PERFORMED: DESTRUC710N METHOD:(CHECK ALL THAT APPLY 4w ) 7 #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WILL IDS: 5cc 7-4hl-r- / ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS 59C Tib,c 1 ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIETYPE TO BE USED= AUGERS ❑ HOSE XPIPE ❑MUSHROOM CAP AT(>3 FT) FTBELOwURFA E COMMENTS Ste W -k7PA•,, 04,4_+ Tu/.} 1g, Zol-L 4,r dc5frycf.•. Mcfl.-rd -Sem E�Vjw"' �PJ�Yv 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTSuV, I hereby certify that I have pre ed this applicationrd that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations and alI ica alifomi s. Signed Title/Company 7CO�o �✓�ri► /7pt7� Print Name P-11 01A 64- U AtJ DsJu ENA6v Date 3/o 13 DEPARIMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS S L-1 -I p/ 57-kr-1Er WORK PLAN DATED O/ APPLICATION ACCEPTED BY , Ui ICGCI DATE EA GROUT INSPECTION BY FINALINSPE TIO DATEJ6� L DESTRUCTION INSPECTION BY < DATE b" <� / COMMENTS/CONDITIONS: S e �o� �C�rce^ ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 3502 $125x0_.3 2375- d"UIV 6-P 3'/5! 3 SR# S! 3503 3�s RO# (3500) PR# (2900) C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC 1 of 2 3/6/2013 9:36 AM