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�¢4M SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 _ UNIT IV <br /> Telephone:(209) 468-3454 Fax:(209)468-3433 Web:www-sigov.org/ehd <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELDS AND GORINOS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-RF;FUND60LE PERMIT EXPIRES 1 YEAR f3DM 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 DevelopmentttTitle,Chapter 9.1115.3,and the Standards of the San Joaquin County Environmental Health Department, <br /> SitPropt e�rty �„1 �3 t�!1 Crosti Streot _ j,j City 2iP , APN <br /> Owner.- Address S City zip 15 D-1-Phone <br /> C-57Contracar pent?l�ke_ A�dxdress i .�� City 1� Lic Cltl(,� Phone 5 bi51-c�1Gf� <br /> Cons uItanVSubCntr .S1At3clress Ok�,V City Lig 7� wi$ Phone. <br /> Billable Parry Address City_ `Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO t3E PERFORMED: <br /> NEW ELU80RING(CPT,G£OPROSE,HYDROPUNCH•HAND-AUGER,OTHER) v \ <br /> OIL BORING IDs 5%1 <br /> ❑WELL IDs <br /> ❑OTHER IDS ` (� <br /> PE&R OF WELUBORING INSTALLATION TYPE NSTRU ION SPF-CIFICATIONS V1J <br /> _❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapour WAtor ❑HAMMER)ORIVEN CASING THICKNESS TYPE OF CASING: ©STEEL ❑PVC Q OTHER <br /> SOIL VAPOR PROBE Cl MUD ROTARY DENTH OF GROUT SEAL <br /> _TREMIE TYPE TO aE USED: L1 AUGERS ❑HOSE Q PIPE <br /> ❑SOIL BARING PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes Q No(MAXIMUM FRaU FALL DEPTH IS 3O FT) <br /> 17 INJECTION(Lti.Airfw <br /> Snam( Omnm/Q�HAND AUGER GROUT SPECIFICATIONS /VG4 t CC04&"" �" <br /> yQ OTHER: Q OTHER: APPROX.BORING DEPTH ❑BOL1'EO TRAFFIC BOX OR E7 STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes!Casing Dle: Cesing Dapth: Boring OI&: <br /> COMMENTS: � <br /> NOTE: OFFSIT15 WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: STRUCTION METHOD.ICHECK ALL THAT APPLY <br /> #OF WELLS)TO BE DESTROYED <br /> WELL IDs: Q OVER-BORE DIAMETER OF INCHES TO DEPTH of FT <br /> ❑PRESSURE GROUT TO DEPTH OF <br /> GROUT SPECIFICATIONS .��-Fr BELOWSURFACE - <br /> TREMIE TYPE TO BE USED:Q AUGERS HOSE PIPE ❑EXPLOSIVES FROM To FT BELOW SURFACE }Wyk <br /> COMMENTS Q MUSHROOM CAP AT L3 FT) FY 13ELOW SURFACE <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations nFa taws. <br /> Signed Title/Company P—tr <br /> Print me 4f"Cf Date 1�It' 1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FIL .SITE ADDRESS ��� <br /> WORK PLAN DATED tl 12.L69 - <br /> — <br /> APPLICATIONACCEP OB il/C DATE ISSUED I I /1 AREA <br /> _1�f3 <br /> GROUT INSPECTION BY FINAL INSPECTION BY_ d/,' DATE / <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: ri4 tof rblee LJe�h 1/iD—1 (aNG/'rFic Nr ai Lt'T- - 10622ts-7 <br /> ACCOUNTING ONLY; AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK* RECV'D SY DATE SERVICE RO# INVOICE <br /> 350 _ REQUEST PREF <br /> $122x I 122 `!NT/ SR# 44 /6/0 <br /> 350 3 36/ 3��— 3oyy <br /> 3500 <br /> 0365 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C•57 LETTER OF AUTHORIZATION TO SIGN PERMITENCROACHMENT DOC <br /> EMD 29-01 g7/2B11O <br /> WELL PERMIT APP <br /> TT/Z0 39Vd 1­10310dIAN3 X3dd LLTOT989T6 LE:ET OTOZ/0T/TT <br />