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77JI/la�oiirr r"�" <br /> HJ.IVBH IVIW]"NO81AN3 <br /> q.,4..1.N. • SAN JOAQUIN COUNTY • moFILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> �g ��CC <br /> y s 1868 Hazelton Avenue, Stockton, CA 95205-623N1T IvnoN <br /> a Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.sigov.org/eh <br /> �rFOR <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <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 made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> 10 1-02 0'h <br /> Site Location g30 &ic Aje R.k.d Cross Street &cA ,1 Lsi.e= City/State Ripoo Zip C4 APN 2�,i-oz0- 07 <br /> Property <br /> Owner k,F. ",k 7r-r:. Address 938 12o&a City/State off Zip fit Phone <br /> C-57Contractor tz6c'11e. P1-"(i&4 Address '3X32 QV• ee-r G.'r• City/State Qaicko Phone 41r.'Wa3 -ilrah <br /> Consultant/Sub Cntr �lir1 Address '351 RuE55 x je & City/State RlDoo Lic -CA— Phone <br /> a <br /> E. 2og-S9al-2ooc( <br /> Billable Party 6r. R' Address 3'51 Rues5 ALL l City/State 04 Zip CFF Phone 'zV9-5`r4-z0 y <br /> GIS Coordinates:X 37 7C 0-4 1 Y _1`2.1. 87YYG <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> 04 NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) - <br /> ❑SOIL BORING IDs G <br /> ®WELL IDs EW- 1 / F_W- 2 <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING (M HOLLOW STEM DIA.OF BOREHOLE 12// 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 3 ®EXTRACTION:Vapor/ ate 0 HAMMERIDRIVEN CASING THICKNESS SCI7, 40 TYPE OF CASING: 0 STEEL ID PVC ❑ OTHER <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL 31/ TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE N PIPE <br /> _0 SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:CA Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION(i.e.AirSoame.Omne10HAND AUGER GROUT SPECIFICATIONS /V7 * C'eanelal- <br /> _0 OTHER: 0 OTHER: APPROX.BORING DEPTH (00 1 0 BOLTED TRAFFIC BOX OR 13 STOVE PIPE <br /> CONDUCTOR CASING P No 0 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 ALLTHATAPPLY) <br /> _#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS O EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <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 <br /> Regulations,and/a/ll applicable C1Il1alifornia laws. <br /> Signed 1" ,`i�[.,en.rrL7cAt)L Title/Company <br /> Print Name /iris Date �d�17�4odr� <br /> DEPARTMENT UUS�__r� <br /> E ONLY <br /> SITE An <br /> SITE MAP IN UNIT IV FILE-SI ,D�DRESS Q32 RON724e" Ann <br /> WORK PLAN DATED �fbRS E (S / // cr <br /> APPLICATION ACCEPTED BY J. _yo fq KuW DATE IS � <br /> GROUT INSPECTION BY FINAL INSPECTION BY C `trCfanr?arin.r���r <br /> DESTRUCTION INSPECTION BY 0 U DATE <br /> COM ME NTSICON DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 250 l $130x / 37// Cloaa,T✓r /o-zf l sV# O 36 <br /> LZ;L <br /> 2 ew7cey?�4v 3 29 0 5 75?c� <br /> C-57WC I/ WAIVER_pt/�}C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCR ACHMENT DOC I✓04 <br /> E 29-01 7/24114 WELL PERMIT APP <br />