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=USE i <br /> ,oAa �tl SAN JOAQUIN COUNTY <br /> MAY 13 2013 <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> f CA 95202-3029 EN ' ^ °' ' SIT - MITIGATION <br /> a 600:East Main Street, Stockton, MCNMEl'Mi s�. <br /> . •.- p Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.s' o�'r`lr'J .Frr4�i�`FI IV — <br /> Q�lFORt�` - <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> 0 &Aq - NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is tW.by made to San Joaquin County for a permit to construct andlor install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-11 3,an the St ndard�!o the San Joaquin Copy 'Environmental Health Department. <br /> Site Locatio t POW ross treet City �taG�Zip ! U� APN +Qt o <br /> Propertyp <br /> Owner t O� Address ��� Nr. u I /YAG ity t7n Zip -[531 Phone f! 'q <br /> C-57 Contractor, Pik � vl Address C' City ey Lic 5 Phone b �G3 NN�'' <br /> Consultant/SubCntr Address 937 LW City Lie Q0ZZ 7 Phone L S)! ��3W <br /> Billable Party Address 7 Gf.+� City S Zip �1 Phone } <br /> GIS Coordinates:X32 ,2 (z 532-Y —0-1 • );O�� <br /> i <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLlBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDS <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE ti+#OF WELLlBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMEPJDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP!CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ❑INJECTION ❑HAND AUGER GROUT SPECIFICATIONS <br /> �❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑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: CHECKA THAT APPLY <br /> #OF W ELLS)TO B DESTROYED ((� VER-BORE DIAMETER OF NCH S/T�O DEPTH OF !;;b <br /> W LIDS: r Ci 'r I PRESSURE GROUT TOOEPTHOFV FT BELOW SURFACE <br /> GROUT SPECIFICATIONS •� of c ML' ❑ EXPLOSIVES FROM T FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: UG RS HOSE ❑PIPE �IQUSHROOM 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 hhave prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and a I pplic le California laws. �G�rsf <br /> Signed Title/Company .� <br /> Print Name Date <br /> DEPARTMEN�T USE ONLY C /� <br /> SITE MAP IN UNIT IV FILE-SIT ADDRESS 4 I/ +Q, C.0.0 <br /> WORK PLAN DATED 471ekl,301 <br /> APPLICATION ACCEPTED BY DATE UE I 1 AREA <br /> GROUT INSPECTION BY FINAL INSPE TION Y DATE d n <br /> DESTRUCTION INSPECTION BY TE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 2SO� $125x'S �noD 3�97� S !� r SR#0O1o7I(p 1 <br /> RO# <br /> (3500) <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 2M1 01!13112 WELL PERMIT APP <br />