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�oe4t.co • SAN .JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT 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.sigov.org/ehd <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 Deeloevt Tit, ha 95. an`th Stand t. en Joaquin Count Environmental Health Department. <br /> oru11VI [p=��� <br /> Site Location Lo 1vr -f ycor� F ..dCorolss Stret {AI/e4nCityZip ° 5330 AP <br /> N R <br /> fi* e U <br /> Property o � City -3&Owner . / OF te.t�b Address ZiPhone} 44a <br /> C-57 Contractor �ro �^Soli3Address (los- Rooke 5t. city No-sh`, T-% L;e 097/ Phone M��3q[— on <br /> o <br /> Consultant/Sub Cntr Address City Lic Phone <br /> Billable Party Address City Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WO BE PERFORMED: <br /> EW WELL/BORIN (CPT, EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING 78 <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <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: ElSTEEL [IPVC [IOTHER <br /> _I]SOIL VAPOR PROBE [IMUD ROTARY DEPTH OF GROUT SEALTr, 4>S11tTREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE <br /> -"AL0 SOIL BORING ,PUSH POINT(GP/CPT) GROUT SEAL PUMPED:05 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —I]INJECTION fie Air Sparge.Ozone)[IHAND AUGER GROUT SPECIFICATIONS 9 'S <br /> _0 OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CQNDUCTO�2 CASING No❑Y. Casing Dia; CCo�axing Depth: BorJ'�ng Dia: <br /> COMMENTS: Lorry o'F f, t.JJ-tr�1" A'JG I LQ.e�xliook way n,+d Co r^e-r� oY Fo rGf-f tvaod f ,e ood Val <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 WELLS)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 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 /> Regulations,and all applicab Califo�rniaQJaws. <br /> Signed Title/Company 5f cc cO' 460.4 13 kLy p` <br /> S <br /> Print Name Date— <br /> ,, CC DEPARTMENT US ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 0Afl G' / /i�L-�� <br /> WORK PLAN DATED t zof I <br /> APPLICATION ACCEPTED BY DATE ISSUED !O V f AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE/D / 1/ <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMEN TSICO N DITI ONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> J704; <br /> 1 <br /> / REQUEST PR# <br /> J 1p 04; s 122 x I Z-� - 60'Z.�8 b(p l`I'� l�(��/I SR#00&3 S'I0 <br /> RO#190 of/ <br /> �� )r <br /> 37S7- " 3500 7 u <br /> R# <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 WELL PERMITAPP <br />