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� . ituElIVED <br /> �a"I'�•. SAN JOAQUIN COUNTY <br /> MAY 13 200 <br /> ,� so <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> r-�rS TE.MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029EN�rr,•OINMENTAL' 'LUAIT IV <br /> Telephone: (209] 468-3147 Fax: (209] 468-3433 Web:www.s' tai�o�'le ?�'t'I� <br /> R�1FOR <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 her 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 evelopment Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> PA(� e0 e. Cross Street City ( Y1 Zip�(2 APN <br /> Site Loca ion <br /> f Property ��)� r lock <br /> �/ [� <br /> Owner deo Address nG ) City J� lock Zip �5 by Phone �� '��� ` yl_S <br />'R. C-57 Contractor Address a-� �'t If' CityrrP✓l Lic� �Phone <br /> Consultant/Sub Cntr U S City Address �y �tN �13C1C/ <br /> `b� io Lic"n��2 Phone ,.,_l <br /> Billable Party J.�R . Address 7 I)—v City vl Zip 1�Phone gds 5.11-.3t�.c../ <br /> GIS Coordinates:X Y — 111 ,. 121065 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLlBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> I` ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IQs <br /> TYPE&#OF WELLI'BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />` _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN 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{Le.Air Soaroe.Ozone/❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> C l CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: 96 (TE WEL 8 ORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTIONMORK TO BE PE F M DESTRUCTION METHOD: CHECK ALL THAT APPLY) r/ <br /> #OF W F - t] ROVER-BORE DIAMETER OF IN ES TO DEPTH OF X� FT <br /> ELL IDs:M PRESSURE GROUT TO DEPTH OF '0 FT BE40W SURFACE <br /> GROUT SPECIrICATIONS on vc &A-e-71 ❑ EXPLOSIVES FROMTO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERS E]HOSE C] PRE [--]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,an II app/- able–California laws. ( �` <br /> Signed TitlelCompany (_ !U[ 2� <br /> Print Name IOIYI 11 j1haqDate 5- 9 J 3 <br /> SITE MAP IN UNIT IV DEPARTMENT USE ONLY ( <br /> WORK PLAN DATED FIDE SIT DR eS� .0 v� C d <br /> APPLICATION ACCEPTED BY J DATE IS ED i � AREA f <br /> GROUT INSPECTION BY FINAL INS EC tON BY DATE�J <br /> DESTRUCTION INSPECTION BY a°"�EDATE ! S •� �r �,_ <br /> COMM ENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> $ 125 x b � SR# 71 <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 29-01 01/13/12 WELL PERMIT APP <br />