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PAY C, <br /> A. g Ulf . SAN JOAQUIN COUNTY RECL C <br /> ENVIRONMENTAL HEALTH DEPARTMENT AUG 2 4 piLOP <br /> MITIGATION <br /> �. 600 East Main Street, Stockton, CA 95202-3029 SAN JOA UIN COUNTUNIT IV <br /> P ♦ Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigKRTMENT <br /> r-6 ire <br /> WELL & BORING PERMIT APPLICATION <br /> R WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> �,��\`p)� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby macre 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 DevelopTent Title,Chapte�rr99-1115.31 d the Standards of the San Joaquin County Environmental Health Department. <br /> I <br /> 9 '\ "gross SCity/ /M Zip APN LZ 1 Z b O�3 <br /> Site Location <br /> OwneProper {" Address �(� �,rr-COVK City �,,r,,,.�.-{� �9Pt Phone._ ; <br /> _}Address r B1St'r City 4 1rc Phone l—�Ua yrl l�/35S <br /> C-57 Contractor "( ?�: d' ;� Ip <br /> ConsultantlSub Cntr Address City Lie Phone <br /> Billable Party <br /> Address City Zip Phone <br /> — <br /> 3ILZRGIS Coordinates:X Y i( <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL to <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE _❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _[I EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: [ISTEEL ❑PVC [IOTHER <br /> _[ISOIL VAPOR PROBE [IMUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [I AUGERS [I HOSE [3 PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION fl A,Spam,O 1❑HAND AUGER GROUT SPECIFICATIONS <br /> OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE !� <br /> _❑ — <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:(CHECK ALL THAT APPLY) <br /> __J_#OF WELL( I`Y TO.BE D^ST OYED ❑ PRESSURE DIAMETEREP INCHES TO DE PTHEL FT <br /> WELL IDs: �1.(A�(/ � ❑PRESSURE GROUT To DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: ❑AUGERS ElHOSE ElPIPE [IMUSHROOM CAP AT(>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 California law r-.- (\ <br /> Signed ,fyAn� � Title/Company ` Dy <br /> Print Name d �,�' ] n� Date [)"Z Lk - '&'o b <br /> DEPARTMENT USE O kil <br /> Y <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS ' <br /> WORK PLAN DATED 7 , 2'J I <br /> AREA <br /> APPLICATION ACCEPTED BY <br /> GROUT INSPECTION BY FINAL INS ECT DA <br /> DESTRUCTION INSPECTION BY DATE /Q <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# <br /> 20 Z <br /> $122. 1??r2. sR# DD bit L <br /> RO# <br /> ctQ 3500 <br /> P # <br /> 90 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENn QCROENW DO PERMITAPP <br /> EHD29-011 07/28110 1' C1 - <br />