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'E 0V <br /> ,oAaE so .SAN JOAQUIN COUNTY MAY 132013 <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> L-Nl'iR'NMENiTALSITE! ITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 ^'P �1r� UNIT IV <br /> a pE�?511i7/��r�E E <br /> 4.._ ...% Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigoV.org ef�i <br /> �F'o a <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> a 0-"(- NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is here de 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 Qev opme tItl Chapter 9-1115.3,aN the Standards of the San Joaquin County Environmental Health Department. <br /> G05 'f d <br /> Site Location SJ �' 0 n toss tree MASCOCity���Zip , APN rr11 <br /> Property P a t9X ey Cit n zi qS�O) Phone o� '/�165 <br /> 6 <br /> Owner Address y p <br /> C-57 Contractor W a Address 2a r City ,cin Lic�Phone `7�h —7 f�3�+ <br /> Consultant/Sub Cntr Address 57 City Lic G�Phone W6 `5,1!-1360 t <br /> Billable Party Address ti1G.! City Zip Phone 2?Z -,7J- 73G� <br /> GIS Coordinates:X –1 - c 111 . 1 X 533 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> Cl WELL IDs <br /> ©OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS i <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN 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(i a wr Soarae.Ozone/❑HAND AUGER GROUT SPECIFICATIONS <br /> i <br /> _ t 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.PERFUC ME4 DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE D self D _r O J\ n❑OVER-BORE DIAMETER OF INFO TO DEPTH OF FT <br /> WELL IDs: IJ�PRESSURE GROUT TO DEPTH OF �V FT BELOW SURFACE <br /> GROUT SPECIFICATION AA 0I :'; D G ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USES: A�URS HOSE [--]PIPE [MUSHROOM CAP AT(13 FT)� 2 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,and alla cable lifornia laws. _ <br /> Signed Title/Company 5--119-t <br /> z <br /> Print Name r I t Date J "�'t J _ <br /> DEPARTMENT USE ONLY [' /� <br /> SITE MAP IN UNIT IV FILE SITE DDRESS �t/ (7 7 �t1 4— 1 5'aQ <br /> i <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTIID BY DATE LIED AREA <br /> GROUT INSPECTION BY FINAL IN6C ON DATES .D <br /> DESTRUCTION INSPECTION BY E D 2 <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 /> S�Z $125 x 15-113 SR# CO&71 '11 <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 />