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SAN JOAQUIN COUNTY <br /> ORIGINAL <br /> - - <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> I � <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> \herebao, <br /> Tele hone: 209 468-3147 Fax: 209 468-3433 Web:www.siaov.orci/ehd _ -NIT <br /> WELL & BORING PERMIT APPLICATION <br /> WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDApplicto San Joaquin County for a permit to construct and/or install the work described. This application is ma06 in compliance with San <br /> Joaqut Title,Chapter 9-1115.3 and th7a,//I/s"'Rd <br /> of the San Joaquin County Environmental Health Depa0ent. <br /> Site Lrn on Ave Cross treet /State Stockton,CA_ 9520Lip 9 APN 072-420-15 <br /> Property Richard Sola 341 reek Trail ircl Stockton,C 95 9 <br /> Owner Addr ss Cit State dip Phone <br /> C-57 Contractor Penecore Drilling Add 1238 AI e S to A City/State woodland,CLIC 6899 Phone 530-681-3198 <br /> Consultant/Sub Cntr Cook Environmenta ddress 1485 Treat Blvd.,Ste 203 City/State Walnut Cre - A 921387 Phone 925-478-8390 <br /> Billable Party Richard Sola Ad ess 10341 Creek Trail Circle City/State Stockton,Cip 95209 Phone <br /> GIS Coordinates:X Y ✓s�d`� <br /> CONSTRUCTION WORK TO BE PERFORMED: fz'�P� A !� <br /> 17-1NEWWELL/BORING(CPT,GEOPROBE,HYDROPUNCH, ND-AUGER,OTHER) 1 ('C <br /> SOIL BORING IDs — <br /> WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CO STRUCTION SPECIFICATION <br /> _❑MONITORING ❑HOLLOW STEM DIA. \OFOUT <br /> ' ❑M TIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water HAMMER/DRIVEN CASIS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTSEAL )' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOS'4 SOIL BORING ❑PUSH POINT(GP/CPT) GROPED:❑Y s ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.AirSoarae.Ozone)❑HAND AUGER GROTIONS <br /> _❑OTHER: �TUFR APPROX.BORINGP -, ❑BOLTED TRAFFIC BOX OR [ISTOVE PIPE <br /> JNDUCTOR CASIN No Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACC SSA EEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY <br /> #OF WELL(S)TO BE DESTROYED ❑OVER ORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESS RE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOS ES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑PIPE ❑MUSHRO CAP AT(?3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (�IIFTER PERMIT ISSUANCE) FO INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and at the work will be done in accordance w h San Joaquin County Ordinances, Rules and <br /> Regulations,and all a�'e�C li rnia laws. <br /> Signed / P.E- Title/Company President/Cook E ironmental Services,Inc <br /> Print Name Tim Cook Dat 6/12/2013 <br /> DEPARTMENT USE ONLY <br /> 00 x), Sy Tn,FJ <br /> 71 9 <br /> APPLICATION ACCEPTED BI _ ,• YoWKu DATE ISSUE AREA_ <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY r _ DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES rel–INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE R # INVOICE <br /> REQUEST PR <br /> �C(O 37S (3500) <br /> PR# <br /> (2900) <br /> C-57 L/ WC r/WAIVER //1/ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD:9-01 5/09/12 �T WELL PER7P APP <br />