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U �\ iIJIIY �� - <br /> pp4 IN-,00 1� • SAN JOAQUIN COUNTY <br /> n. t .c <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> c•..,,1 P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:wwwsidov.orglehd — <br /> ,trko � <br /> WELL & BORING PERMIT APPLICATION meg/ <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 Sawn L\ <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. lyN� <br /> 3� 3M _Q - Aft*XA— City m� 1�1�xfllZipQ�3 APN 0Z(2-50 27 <br /> Site Location . Cross Street /r / �u yi <br /> Property it POBV?( 2 i f City Attsa/67 Zip �3�(g Phone, <br /> Owner c�krn E'Q�PM'16T rA�,,vvd.l�drrress r''11/°F'/H_" 000 ��;k <br /> C-57 Contractor A-//ct�Ef/2g�IN. QKWdress � �i_�w4 City OtJ>4 '"'Llc; Phone / <br /> Consultant/Sub Cntr <br /> Address City Lic Phone <br /> Billable Party <br /> Address City Zip Phone <br /> GIS Coordinates:X V�2 <br /> CONSTRUCTION WORK TO BE PERFORMED: RECEIVED <br /> ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs J <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS H�i ENVIRONMENTAL <br /> c `` <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE _ ❑MULTIPLE CASINGS I]MULTI-LE WELE CASING DIA: A <br /> _D EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC ❑ OTHER <br /> _D SOIL VAPOR PROBE D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes D No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _D INJECTION(is A 5 Ozane)D HAND AUGER GROUT SPECIFICATIONS <br /> _D OTHER: <br /> OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth:_ Boring Dia._ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD•rCHECK ALL THAT APPLYI <br /> #OFWELL(S)T9ppp-BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> /�A�/� ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> WELL IDs: ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> GROUT SPECIFICATIONSMUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE 11PIPE Li \ <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certity 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 Ca�-lor�niia lave s. <br /> Signed �.Tr� S t�'yJ�IJ Title/Company <br /> Print Name <br /> Date <br /> � A %4 �� ��2 N <br /> DEPA T ENT U NLY c <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS e <br /> WORK PLAN DATED <br /> AREA <br /> APPLICATION ACCEPTED BY <br /> GROUT INSPECTION BY FINAL INS TIO DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTSICON DITI ONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# INVOICE <br /> PIE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR## <br /> 7 �� $122x �2L ! SR O / <br /> �P(P RO# <br /> Y� 3500 <br /> 2900 U/4" <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT —ENCROACH WELL <br /> LL PERMIT APP <br /> EHD 29-01 07/28/10 <br />