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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 6 T <br /> aP Telephone:(209)468-3147 Fax:(209)468-3433 Web: <br /> WELL & BORING PERMIT APPLICATION MAY 2 7 2014 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ENVIRONMENTAL HEAL19,1 <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or Install the work described. this application is madP[n-R&%'FAERjqMn <br /> Joaquin County 9-1115.3,andStandarq�oft San Joaquin County Environmental Health Department. <br /> W39� -iv <br /> Site Location &rA" Cross Street L�151S'IL /If R'-�/ Ci(y/State t-.c Zip— APN 2t)'F-021-ol <br /> Property P�-T3;-S ,5.. 1.5co <br /> Owner Addresspeer-on .9One City/State Zip 7 y611 Phone <br /> il C-67 Contractor (�S�e4Je.&jfi-5 6'Address 3,0, 11 City/State rl 0 Phone'i I yo3-113? <br /> 10 4Q 7 S6'1 e <br /> Consultant/Sub tr C Adqness City/State Lic Phone 9/6 <br /> C:Fk ' �cj <br /> �' 5L�' 0, , <br /> Billable Party Lte-' -.0. dress 1,9 V'/,f e, if r3.,A 'Orl� City/State c'-4Zip--&�7 6 Phone-7 b'7-V,3r- -0 <br /> GIB Coordinates;X '3-7. 734P <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> Ej NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> C]SOIL BORING IDs <br /> El WELL IDs <br /> L1 OTHER Os <br /> TYPE&*OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> —[I MONITORING E3 HOLLOW STEM DIA.OF BOREHOLE— El MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA. <br /> -[J EXTRACTION:Vapor/Water [I HAMMERIDRIVEN CASING THICKNESS _TYPE OF CASING: 0 STEEL 0 PVC El OTHER_ <br /> _0 SOIL VAPOR PROBE El MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS 0 HOSE D PIPE <br /> _fl SOIL BORING Ij PUSH POINT(GP/CPT) GROUT SEAL PUMPED:El Yes [I No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —0 INJECTION Q..Air Searge.Ozonel[I HAND AUGER GROUT SPECIFICATIONS <br /> —0 OTHER:— D OTHER: APPROX.BORING DEPTH—El BOLTED TRAFFIC BOX OR D STOVE PIPE <br /> CONDUCTOR CASING D No El Yes:Casing Dia:_Casing Depth:_ Bering Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALL THATAPPLY) <br /> WELLS)TO BE PESTROYED OVER-BORE DIAMETER OF-C _ SCJ TO DEPTH OF C:y FT <br /> WELL IDS: /-tL/-/ 11-44-1 ,PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS'Ovor77� 0 EXPLOSIVES FROM TO_FT BELOW SURFACE <br /> TREMIE TYPE TO BE U�ED�[ AUGERS FIEpPIYEMUSHROOM CAP T <br /> (>3 FT) ELOWSURFACE <br /> COMMENTS (SA ' I , . I " 'e" -Ly14r <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, all applicable <br /> Ipp 9a)IfomIa laws. <br /> Signed Title/Company <br /> Print Name aji AL C, Date <br /> li DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 1-69A)S6V ROTAl, AJ( I 7 <br /> WORK PLAN DATED. !2 261V <br /> APPLICATION AC DATESSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COM MENTSICONDITIONS: <br /> ACCOUNTING ONLY: All)# FAC# <br /> PE CODES FEEINFO AMTREMITTED CHECK# RECV'D BY DATE SERVICE R <br /> PO #" INVOICE <br /> REQUEST <br /> $125x 62< SR;Y CJS <br /> O <br /> 37S R #(3500) <br /> PR# <br /> (2900rl ) <br /> C-57 Iz, WC V WAIVER (LlkC-57 LETTER OF AUTHORIZATION TO SIGN PERMIT v ENCROACHMENT DOC 4/fl <br /> EHD29-01 5100/12 WELLPERMITAPP <br />