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SAN JOAQUIN COUNTY <br /> zo. <br /> ENVIRONMENTAL HEALTi-I DEPARTMENT <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> UNIT IVT DN <br /> -3147 Fax: (209) 468-3433 Web:vmmsigo ot eq'' ' <br /> ..........1� Telephone:(209) 468 —:q4l114 <br /> - <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND R0111519NDANTAL FIEArin <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct ancilor 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 /> wo%e+l zol <br /> .2 Lgo - City/Stalle-f rCLCq, Zip QT(P APN <br /> Site Location Cross Street VV LF <br /> Proport <br /> Owner"VV bj( UV&J�., Address "b0*01I11!n 1201- City/Statezip 9S33:tePhone <br /> .. <br /> U 'M <br /> C-57 Contractor Cacb- IDA% Address (FIX)b QIAIW%�k City/State W'Llc1D Phone 91110 <br /> CormultallUSub Cntr dress City/State Llct� <br /> Billable Patty �01111 oil vroc., <br /> — <br /> Address City/Slate Zip 9�SU Pliona9lb-ffi7- <br /> gr <br /> GIB Coordinates:A y <br /> 3 7. 23 7q.1 -Z-124—SI307 <br /> fC0NSTRUCT�10NW0R �T�O BE PERFORMED <br /> jf�l (CPT <br /> NEW kwizLILIBORI�NG(CPT (-FUIRT'PF WYDRnPI INCH,HAV�D-AUGEP OTHER) <br /> 301L BORING IDs <br /> UVVELLIDs <br /> -1-_]bTHER Os <br /> TYPE&#.OFWELU13ORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> -t��ONITORING DILLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA!-2," <br /> 0 EXTRACTION:Vapor/Water 9HAMMER/DRIVEN CASING THICKNESS 4D TYPE OF CASING: 0 STEEL 1V'pVC 0 OTHER <br /> 0 <br /> —CI SOIL VAPOR PROBE [I MUD ROTARY DEPTH OF GROUT SEAL 23k REMIE TYPE TO BE USEOIp AUGERS ]HOSE PIPE� <br /> SOIL BORING [I PUSH P0114T(GP/CPT) GROUT SEAL PUMPED:LJ Yes'ANO(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> INJECTION Ii e A11S.9M.OVOILI 0 HAND AUGER—GROUT SPECIFICATIONS <br /> _CI OTHER:— C3 OTHER:_APPROX.BORING DEPTH Ej BOLTED TRAFFIC BOX OR -E4S-TOVE PIPE <br /> CONDUCTOR CASING Ej No 0 Yes:Casing Dia:_Casing Depth:_.Boring Ola:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> *OFWELLS)TOBE DESTROYED IL OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL Me: E]PRESSURE GROUT TO DEPTH OF FT BELOWSURFTC E <br /> GROUT SPECIFICATIONS 0 EXPLOSIVES FROM TO_FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:[-]AUGERS 0 HOSE Lj PIPE Lj MUSHROOM CAP AT L3 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 /> Regulationtia b1Nfl California laws. <br /> Title/Company <br /> Pdnt Name 1 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS3 tS 5-, 1-Ifdit,5<n) Roe-") —Cbpbc-5 Ral' � <br /> WORK PLAN DATED rq <br /> APPLICATION ACCEPTED BY 1*11 11"M2 ,.,1 DATE ISSUED_AREA /6757 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COM MENTS/CO NDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# 011 <br /> QUEST <br /> I <br /> PE CODES FEE INFO AMT REMITTED CHECK# Rr:C\rD BY DATE SEERVICE FIR it INVOICE <br /> 170 SRI(1/1 1 $126 x RO# <br /> 790� 375 (50#0) <br /> PR <br /> f"001 <br /> C-57 ✓ WC _WAIVER JU G-57 LETTER OF AUTHORIZATION TO SIGN PERMIT Ll ENCROACHMENT-D-0-C-W'4 <br /> EHD29-Oi 5439M2 WELL PERMIT APP <br />