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` P4gIN•. `/ SAN JOAQUIN COUNTY REC COPY <br /> r.• ENVIRONMENTAL HEALTH DEPARTMENT OCT rrtggOP - <br /> •!�"O '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone:(209) 468-3147 Fax:(209) 468-3433 Web:www.sigJNWE N AI IkNh�#)4 <br /> �EF(M11 iSERVICES <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 Enviro�n(mental Health y Int. <br /> Site Location 1$6 6 7 O-Cob B tac+ZK•1CM"street 1✓r h e/ city/State Lo Y ' Zip . APN 011-090-W <br /> Properrty5✓-ffQf �d-+n�C IIJ� QY5 / <br /> Phone 963-3/6`fOwnenPf- Address Ux 7_49 Ciry/Stte �� �p <br /> Address 5OPfld City/State C•57Contractor Wo0dword Lic4fo <br /> Phone 10 -37'/-'f30 <br /> Consultant/swbGnh Ja,Aj Address 363 2-51 52 5005 City/State 5C�v, Frn„ LicPL Phone `ilS-ZY3'Z/.SO' <br /> Billable Party ,r.¢ J4,.,k Address Sa k . - City/state 5a NIP Zip 4 Y/O Phone <br /> GIS Coordinates:X 62� 5L"1 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ®,NEW WELLIBORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ®SOIL BORING IDs (ALJ--L2/ <br /> ®WELLIDs� f'3- lcl GfJ-2.0 fT W�LIr L7-R'L <br /> El OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ±E.]MONITORING IRI HOLLOW STEM DIA.OF BOREHOLE 8' ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _O EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS Ste( Y o TYPE OF CASING: 0 STEEL 9 PVC 0 OTHER <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL C7 TREMIE TYPE TO BE USED: ($(AUGERS 0 HOSE O PIPE <br /> —L®SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:O Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION(I.e Ar Soam,Ozone)0 HAND AUGER GROUT SPECIFICATIONS Np j-- CP IP'I Cl'1 t <br /> _0 OTHER: 0 OTHER: - APPROX.BORING DEPTH 20 0 BOLTED TRAFFIC BOX OR W STOVE PIPE <br /> CONDUCTOR CASING Ej 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 ALL THAT APPLY? <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 ❑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, all a livable Ca ifo�rr/1a Iayrys,, � /� <br /> Signed Fr��p /sY/f �-�+�/ / Title/Company W�0/ ins <br /> Print Name M 'C-[Ana ��CC.�cp Date /o7/,// <br /> DEPARTMENT USE ONLY <br /> l <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS �� 6 7 n 1 LAfido 8 8lIAAK Q Zf <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY -IYOAT AREA�� <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE R # INVOICE <br /> �f REQUEST ppPRO 77# <br /> 0'-0 / $125x Soo /37'/ 7'r`@ /0-II-/3 SR# (418A <br /> X90 3 37S 375 /� !3�'� RO# <br /> 3500 <br /> PR <br /> 0 0835/ <br /> C57 _ WC _WAIVER�� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT v ENCROACHMENT DOCAle <br /> _ <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />