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;SAN JCIAQUIN COUNTY- WELL-PERMIT-APPL.pdf http://www.sjgov.org/ehd/d01R%1M- "jkt-pd SAN JOAQUIN COUNTY '%Wo, ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION 1868 East Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV •. P Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:www.sigov.org/elu# .� WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATII'AR ZO13 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 is- ode i�c gpli�anre� ttl_r 1r� Joaquin County Development Title, Chapter 9-1115-3,and the Standards of the San Joaquin County Environmental Health Depar, 't v v Site Location �y 9/ s�/[C�' Cross Street &to 5�l'e f City `3aA}�0. Zip 21E3 v APN Property -r- Owner J e dry MDO/'L Address OX &7 City /3`w4r, Zip 9630 Phone(2o9)7'3<-Z 75D C-57 Contractor Address 3 5rO+-v L%ckCeeek b r City 5Mc*f e% Lic -7 2 ago Y Phone C2o 0 Y75--8y4o -- Consultartt/SubCntr- �X EnuJiv"Address- /ZtJt(-pyre s-W46-1 -City �j0A(12�y4.�Lic -7'3 Phone&iu)YS1-Dl7-t(--- Billable Party Address City Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WEWBOR!NG(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTL-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN 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(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION tie.Air Soarae.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 & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS r'L-eTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELLS)TO BE DESTROYED � ❑OVER-BORE DIAMETER of INCHES TO DEPTH OF FT WELL IDs: 5et Tahlt / H+y-+ rI,A1W'14 Ml(+1_�COcsy El PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS 59,CT^6ic ❑EXPLOSIVESFROIA TO FT BELOW SURFACE TREMIETYPE TO BE USED:JKAUGERS ❑HOSE JZ PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW ,URF-ACE COMMENTS s!t warE,O/sn o44ee+ T�/,,} /� 2v/2 dc5lrvc%.w. /etc kA-d-See E Q/ y f ==� Gl�-l�i'v 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS I hereby certify that I haveprepKed this application d that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations and all a liI a aliforni s �. Signed Title/Company Print Name W^+cKAEL UAtJ Date 3 Ce /3 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS Sl-/9/ 57-kC WORK PLAN DATED / APPLICATION ACCEPTED BY DATE 1 w '- -,.,,AREA l GROUT INSPECTION BY FINAL INSP TI N BY AT # DESTRUCTION INSPECTION BY //DATE C1/ /9 COMMENTSICONDITIONS: a ✓ o y r d 1!s / L. -u ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMTREMITTED CHECK# RECV'DBY DATE SERVICE RO# INVOICE REQUEST PR* I SC?Z- 7 0�5 /y Ca��iEe 3—fl/3 SR# 4 2 $125x 375 375 375 Roo) PR# (2900) C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC 1 of 2 3/6/2013 9:36 AMS