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SAN JOAQUN COUNTY-WELL-PERMIT-APPL.pdf http://www.sjgov.orglehd/docs/WELI PER 'ff-APPL.pd <br /> o°'`��''y ��✓ SAN JOAQUIN COUNTY Iy�� <br /> ENVIRONMENTAL HEALTH DEPARTMENT LO <br /> MITI <br /> y { 1868 East Hazelton Avenue, Stockton, CA 95205-6232 e ­' <br /> UNIT IVnON <br /> P Telephone: (209)468-3454 Fax:(209) 468-3433 Web:www.siciov.org/elvel -�� <br /> fv c� <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIQR 1 Jr 2013 <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�r�, e�n,c nce,w n <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Dep�rSfi Int =,!Tr1 <br /> Site Location Jry 9/ ` S�fCC f' Cross Street LO to Vree 7 City 84rt Zip �7s3 v APN <br /> Property -7 <br /> Owner ✓ e fry �oOI't_ Address /' V 13 OX /07 City �`�� Zip 9S3a Phone(ZO9�Y 3�Z 7S0 <br /> C-57 Contractor %1 f W br%/l%nS Address 3?'OL9 4%ckCleek. L),/ City 5iVc-AfOn Lic -72.0ry6q Phone(2e OT7S-8yv0 <br /> Consultant/SubCntr 13Ptx F�4,lhw'"AddreSS /12yf-{PynAs Wa..j City 0o/a(21'v-t/ Lic -76"VI Phone�9/��r(Sl-Of��{ <br /> Billable Party Address City Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELLIDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION C.eAir Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑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: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALLTHAT APPLY) <br /> ' #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER of INCHES TO DEPTH OF FT <br /> wtLL IDs: 5ec T4blL / ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS SCC Twb/t ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERS ❑HOSE XPIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOWURFA E <br /> COMMENTS Sre work-PAwt&QAee✓ Tu/.q /4, Zoer <br /> l L r dc5f-irycl... M c fl.�d—Scr- �f� �PJ v <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> 1 hereby certify that I have pre ed this application d that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations and all Lica alifomI s. ,/ �. <br /> Signed TitlelCompany Ito 10 ,' c,u1 y�1 AP <br /> Print Name 1"l c/•/-4 E[_ UAtJ bGAJ ENA6v Date 3 !3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS S'-/9/ 57-kegr <br /> WORK PLAN DATED 'I r I I~H 1 (" <br /> 20/ <br /> APPLICATION ACCEPTED BY U !C DATE 1 ED 'Z -!3 AREA l <br /> GROUT INSPECTION BY NALINSP TI NBY ATEG 3 <br /> DESTRUCTION INSPECTION BY `L r.� DATE / <br /> COMM ENTS/CO NDITION S: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> 9 REQUEST PR# <br /> 5C� $125x2-3 2375- 3� lft49 Loutii6-Q SR# S/ <br /> 7 RO# <br /> (3500) - <br /> PR# <br /> (2900) <br /> C-57 INC WAIVER C57 LETTER OFAUTHORIZATION TO SIGN PERMIT [/ ENCROACHMENT DOC <br /> 1 of 2 3/6/2013 9:36 AM <br />