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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> ' ` SITE MITIGATION <br /> • 600 East Main Street, Stockton, CA 95202-3029 1 y <br /> Telephone.-(209)468-3454 Fax(209)468-3433 Web:v,?, ,­ ii 4, <br /> , 1-1�, tc <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDA'N <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> an <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicationENVIVIONMEwrAl-tj&',Lj�i <br /> 9 <br /> -1115.3,and the Standards the San Joaquin County Environmental Health Depa'rtm'%enV. TP&�iW&"t' <br /> Joaquin County Development Title,Chapter 9 is <br /> Site Location- V-70,e2 740,1-rfi>-11 Cross Street Z2 a 664 s" City i- ZiP-26'A APN 01Y,-�a&l <br /> Property <br /> Cit <br /> Address iz :, A <br /> y Zip '?5,,Z Phone <br /> Owner 7# <br /> C-67 Contractor Address b"('k City Licl?,0961f Phon <br /> Consultant/Sub Cntr Add 4ecity �X—OtJ15-- <br /> LiG. 7:5�j Phone -45 .,2 <br /> Billable Party Address City Zip—Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERF .ME�Q-:­- <br /> NEW WELLIBORING(CPT,GEOPROBE YDROPUNCH AND-AUGER.OTHER) <br /> f9 SOIL BORING IDS v <br /> El WELL IDS .5-4 ; z <br /> El OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> El MONITORING [I HOLLOW STEM DIA.OF BOREHOLE/ �j"/ 0 MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vaporl Water 'R HAMMER/DRIVEN CASING THICKNESS " TYPE OF CASING: [I STEEL 0 PVC 0 OTHER <br /> —[3 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL-21.'! TREMIE TYPE TO BE USED: E]AUGERS E]HOSE 0 PIPE <br /> 2XSOIL BORING [I PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes fd No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> E]INJECTION(i.e.Air Spame Ozone)0 HAND AUGER GROUT SPECIFICATIONS c-%A?s--5 <br /> 0 OTHER: <br /> OTHER: <br /> APPROX.BORING DEPTH El BOLTED TRAFFIC BOX OR C3 STOVE PIPE <br /> CONDYCTOR CASING P No 0 Yes,Casing Dia:_Casing Depth:_Boring Dia: <br /> COMMENTS: '5f-P_� t�40 /W?l - <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 F_INCHES TO DEPTH OFT <br /> ❑PRESSURE GROUT To DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO_FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:[:1 AUGERS ❑HOSE [I PIPE E:1 MUSHROOM CAP AT L>3 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 applicable galifornia laws. <br /> Signed _ -- -­­,-Z' <br /> -' ;, Title/Company ""'o,,1 :E <br /> Print Name <br /> .5- <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS A <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> OMMENTSICONDITIONS: Z< I t -AAX�f <br /> ACCOUNTING ONLY: t# FAC# <br /> AID# <br /> PE CODES FEE INFO AMT REMITTED CHECK—# RECV'D BY DATE SERVICE Ro <br /> REQUEST PR# INVOICE <br /> $122 x SR#00&7-S.2;F <br /> Z9.0 7 t I KU# <br /> (3600) <br /> PR# <br /> (2900) <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PE <br /> EHD 29-01 07128/10 PERMIT _ENCROACHMENT DOC <br /> WELL PERMIT APP <br />