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FILE COPY: <br /> :In. SAN JOAQUIN COUNTY — <br /> ° . .04 LOP <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION <br /> - 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> • iq.. : bd <br /> �;;P Telephone:(209) 468-3454 Fax: (209)468-3433 Web'www.sagov.org/efid <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 <br /> Title,,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location Wl�� YULE 4��. _(Cross Street Q%va l ((� City S .L:fCr/1 Zip (i 57�� APN <br /> Property q ( ( S <br /> Own.,_&4 '' 1--l-II. 'yr1't{ (r ' dAddress 1 i�I U T4'VI_Q-(II a l d sty l k -t'S i ip (0 v Phone lu L(a l {� <br /> C-57 Contractor �'VbC, Address �Ci� Fl{ City j Lice'Phone t< <br /> ConsultanUSub Cntr QIP] �_-_ Address l 1 City (�I NUIc Phone 1 I I([J {-�LfOt) <br /> ( Y <br /> BillabloParty __Nhh V SP Address .��� 014w K.�1 City �'lti 6i��Lip S c TCS Phone( (�k).k)r"1 0L W <br /> GIS Coordinates:X t0[ Y__ 2I_ 2 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPRODE.HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDS <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE <br /> ____[3 /�^�'�Y/n <br /> MON;IORING El HOLLOW STEM INGS❑MULTI-LEVEL WELL CASING DIA: <br /> El 'CASING! <br /> _❑EXTRACTIONS Vapor/Water []STEEL [IPVC ❑ OTHER <br /> _'E3 E] <br /> SOIL VAPOR PROBE MUD ROTARY ,, O TYPE TO BE USED: ❑AUGERS [:Ip HOSE PIPE �4�! <br /> _D SOIL BORING ❑PUSH POINT(GPI CPT) ryI� M FREE FALL DEPTH IS 30 FT) <br /> _❑INJUCTION II a Air 3Lkar Ora of❑HAND AUGER <br /> _-❑OTFIrR. ❑OTHER:_ ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> Casing Depth: Boring Dia: v <br /> COMMENTS:'O"tM Wk, NtW Set M(!fk1y'1 Oy'I reilAVA a Ly <br /> T J—' tJt louty Mil <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRI )R ENCROACHMENT PERMITSt'vi0 to AVI I <br /> eirKnJ <br /> DE$TRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) (US117 <br /> _�_#of Oho/I(ci TO nr- nP9TRnvrn OVER-BORE DIAMETER OF INCHES TO DEPTWF FT I., r 14. <br /> WELL IDs:, ______-_- __ _ PRESSURE GROUT"ro D£PTH OF I'T BELOW SURFACE <br /> GROUI SPECIFI ATIONS EXPLOSIVES FROM TO FT BELOW SURFACE <br /> I REMIE TYPE TO BE.USED:QA GERS J]HOS;ff PIPE ❑MUSHROOM CAP AT L3 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 /> Regulatlop all pplicablo CWitojoNa laws- <br /> _ <br /> Signed ���� Title/Company <br /> � 2e ___- <br /> Print Name ,_. J 6cZ <br /> DEPARTMEVI US ONLY Z,0 <br /> 0 Q_�l <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS �, <br /> WORT(PLAN DATED 9-�- G — <br /> APPLICA TION ACCEPTED B DATE ISSUED l�_ "l AREA <br /> GROUT INSPECTION BY __� FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY — DATE__ <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC* _-_- <br /> PE CODES FEE INFO AMT REMITTED HECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> I RO# <br /> L3t 600) <br /> — --- -- R# <br /> 2900 <br /> C-57 _ WC _WAIVER _ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC _ <br /> EMD 29-01 07/26/10 — WELL PERtA ATP <br />