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I <br /> 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.siaov.org/ehd HCE' cc <br /> WELL & BORING PERMIT APPLICATION �C® <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION r j <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 mappkappe with San <br /> Joaquin County�tDelv'elop�m)ent Tide,Chapter 9-1115.3,and the Standards oftheScan Joaquin County Environmental Health Department. if.DdTa p 1 � <br /> Site Location�qql /VIVV Cross Street V�. k434nn7+vn J _ City cK7 Zip'75-,Z S <br /> 7 _ •� APN b <br /> Property / �+ / <br /> Owner o 00S-16-k6^ � <br /> Address O W r` S City Jfbc_ltifb✓+ Zip ILO- Phone Z0ffAy6_, oaf`( <br /> C-57 Contractor 6regj Dreffno Address g City Li.of S74 S Phoneg2S:313,SB00 <br /> Consultant/Sub C All <br /> AddressIS— S(.J� i�✓Cnc� City p�QAY- Lic 2LPhone SVI U V.q-•a`f <br /> Billable Party All Crze k Address " City '' Zip "'' Phone <br /> GIS Coordinates:X Y Q fi'Z O <br /> gqNSTRUCTION WORK TO BE PERFORMED: <br /> j 'S NEW WELUBORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHERI <br /> ❑SOIL BORING IDs <br /> $WELL IDs P5R P S IV G -7_ <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> t`�MONITORING t}KOLLOW STEM DIA.OF BOREHOLE �__❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: j <br /> _O EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS p2�'Ste(^Yo TYPE OF CASING: ❑STEEL KPVC ❑ OTHER i <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS 0 HOSE ❑PIPE j <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED'❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 Fr) <br /> __❑INJECTION(i.e.Air SmrQ&Ozone)❑HAND AUGER GROUT SPECIFICATIONS D,t.AS da� .( C Pl ern f er s_✓f I <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH o7 Q 3S� .BOLTED TRAFFIC BOX OR ❑STOVE PIPE ik <br /> pp��// / CONDUCTQR CASING EKNo❑Yes:Casing Dia: Casing Depth: Boring Dla: r <br /> COMMENTS:£- AI '�'� Screvt�( S'-a0 ; f S' 14VC--ZM-R 64r-t-4 '3o ^3 Y' � € <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DE&TRUCTION METHOD, E L THAT APPLY1 <br /> OF LL SJ TO BE DESTROYED $LOVER-BORE DIAMETER OF- INCHES TO DEPTH OF_:�f_FT <br /> WETIL IDs: S C- zm PRESSURE GROUT TO DEPTM OF FT BELOW SURFACE <br /> GROUT SPEC (CATIONS (]EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS n HOSE 0 PIPE MUSHROOM CAP AT(>3 F: 3 FT BELOW SURFACE <br /> COMMENTS <br /> I <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and I <br /> Regulation all applicable California laws. LL / <br /> Signed Titte/Campany fLT h C�rae.L <br /> Print Name 3 Date l r <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS Mx- 1 eC <br /> WORK PLAN DATED D <br /> APPLICATION ACCEPTED BY DATE ISSUED U AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: r!2 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR III <br /> 6 a-- <br /> $122. L (� // J C� 14 1.s'1 SR# DObZS <br /> LPr RO# <br /> J asoo <br /> PR# <br /> 2900 <br /> G-57 WC _ WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 WELL PERMIT APP <br />