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SAN JQAQUIN COUNTY- WELL-PERMIT-APPL.pdf http://www.sjgov.org/ehd/docs/WELJ—PERMIT-APPL.pd Aa`'�y SAN JOAQUIN COUNTY � O R z ENVIRONMENTAL HEALTH DEPARTMENT LOP y ` 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATIONUNITIV Telephone: (209)468-3454 Fax.(209) 468-3433 Web:www.siclov. org/eN -�� --• ,F}�''- �jFCRa IIS 4 arca�-f�l7a:s:a is .''�':T,� WELL & BORING PERMIT APPLICATION L�-.. FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIQ�L�R 1 ZO j NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to S n �agi1n County for a permit to construct and/or install the work described. This application is�u��d {n,c ce,w1 fan Joaquin Cou9t Tbe,6h�pter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Dep�TfrlSIV'_'��iy'�f j �i`� 1-�r�iV�I��ar(�1. (,•, Site Location �y�/ /F„s�/CCf Cross Street tA' S IC f City /3441 0. Zip 2s3O APN ZScSU1�z" Property —(- Owner ✓ t dry 1_1400/L Address PV a1C X07 City /340 Zip 9 Sad Phone(2o9J 7.3<Z 750 C-57 Contractor ' /Address 3�a� l��kC/ee� b,,- City 5� 1�►'� Lic -7 zo fo q Phone(Ze9)T75--f�yod —.Consultant[SubCntr-.14P-{-X-F-4yb'W"Address--//Zgc(Pyty-s w'.!j -City -76CA Phone(9��-Ys1-a�-7-r( Billable Party Address City Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER) ❑SOIL BORING IDs ❑WELLIDs OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _0 MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASINGTHICKNESS 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 C.e.AlrSoaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDU CTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS I'ESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) t OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT 4 LL IDS: SCG T46/c / M&j Q PRESSURE GROUT To DEPTH of FT BELOW SURFACE GROUT SPECIFICATIONS ScC T^6/4 f ❑EXPLOSIVESFROIa TO FT BELOW SURFACE TREMIE TYPE TO BE USED:XAUGERS ❑HOSE XPIPE ❑MUSHROOM CAP AT L3 FT) FT BELOWURFAC�y�,E COMMENTS_ sle WoO'k-Akm 04444 Tu/..I /L1, 70/2 -(a,i desh'ye%w. A-r-4-.-+d—See. E ZD Ap 2 s cg 2 4-in- 1*1164 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS Y�3 I 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 Regulations and all lira alifomi s. Signed Title/Company Print Name UAJ DEN 6;JW=� Date 3 cr /3 pDEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS S 7 57-k WORK PLAN DATED 1 0/ APPLICATI ON ACCEPTED BY GROUT INSPECTION BY RNAL INSPECTION BY 173ATE DESTRUCTION INSPECTION BY X25 ms ATE --- 7 COMMENTSICONDITIONS: ee, r i of �ri�s �•• 5 ACCOUNTING ONLY: AID# FAC# PE CODES FEE INF AMTREMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# SOZ- $125X� ; Il G►vLltiT� 3-/ '! SR# 75 RO# (3500) PR# (2900) C-57 INC V WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC 1 of 2 3/6/2013 9:36 AM