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Pquln. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTIVENT LOP <br /> SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.s' ov.or fe <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 Environmental Health Department. <br /> 7 /f} <br /> rl <br /> Site Location 76 7 GIricAkt-CrossStreet RI14FA 9P. CityST0GKT0� Zip q, LO APN 7 <br /> -z .0w, �60tio,0lp#/zaps AddressG1� B,1100 ✓9Y city S&XAA%FAM Zip 9SS�f1�' Phone(j4)H$-L03 <br /> C-57 Contractor t? %6 ,XW,vj Address 750 110WC RD• City/") RT I✓ - Lic Phone <br /> Consuftant/SubCntrAT6 Address Z5 [y%,,11A CIR. City' � 1 Lic Phone 0") y��/2/7 <br /> Billable Party ATG FOR 610P Address ZS G!/PiW/A G/R. City749!7eT Zip *75S Phone( S) /96-IZ/7 <br /> GIS Coordinates-X g• 0/rf Y _/Z/• 5z y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GE PROBE HYDROPUNCH,HAND-AUGER,OTHER <br /> I- CR SOIL BORING IDs -^ - aGLOta✓- TE-Ai Av <br /> 6- ®WELL IDs_,41W/7 TO (i <br /> OTHER IDs - <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE fI ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA M <br /> _❑EXTRACTION Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS G y0 TYPE OF CASING ❑STEEL Jk'PVC ❑ OTHER � <br /> _U SOIL VAPOR PROBE El MUD ROTARY DEPTH OF GROUT SEAL o ' TREMIE TYPE TO BE USED ❑AUGERS [I HOSE PIPEy <br /> 1r <br /> 1C SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED 1$4 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i a Air Soarpe Ozone)❑HAND AUGER GROUT SPECIFICATIONS CFi l e--T I KZ)a-T <br /> _❑OTHER [:]OTHER APPROX BORING DEPTH qO 16 0 O AOLTED TRAFFIC BOX OR ❑STOVE PIP <br /> CONDUCTOR CASING XNo❑Yes Casing Dia Casing Depth: Boring Dia <br /> COMMENTS: TO yo Q¢p is-dLC�'4 To 60 ' <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) FTBELOW SURFACE <br /> COMMENTS p� <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS •rw�`rJ <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 all applicable California laws. p �D <br /> op <br /> Signed Title/Company �l1• r/�DJ �'t96d'/moi , -�TG f�550G//fT�S <br /> Print Name ��✓ G 1��V1-ESC/ Date /Z/<-.3"// <br /> DEPARTMENT USE ONLY ��" Gum <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS_ , � <br /> WORK PLAN DATED ! 2 2-- /! <br /> APPLICATION ACCEPTED BY DATE ISSUED 3�� I Z 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 CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 5b $ 122x b b, C /- SR#V <br /> 527 3 '5 I f ��7 ( / P R3 00 <br /> 350 � r 2 5 # <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 WELL PERMIT APP <br />