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PAYMENT <br /> SAN JOAQUIN COUNTY .RECEIVE4 <br /> ENVIRONMENTAL HEALTH DEPARTMEN-AUG 2 If 201 LOP <br /> Q: a <br /> �. <br /> 600 East Main Street, Stockton, CA 95202-3029 SAN JOA�uITE MITIGATION <br /> - �1�,Np couN <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:WWWLA QN 1°I i UNIT IV <br /> PGlFOR�\ <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 Development Title,Chapter 9-1115.3,and the Standards of the San aquin County Environmental Health Department. <br /> Site Location Lx Cross Street ity A2A)AA Zip�S� APNZ Z 123 d 0� <br /> Property p <br /> Owner Address, d0 / - - ST-City A/Ii� Zi�Q,S,3` Phone 57 -3 <br /> C-57 Contractor 1 Atrr Glp Z&/J/b�CJlA7urJ7X-Cty l�itjJ -6 Ic Phone /'-7 cr 09 Y8/.33.5 <br /> Consultant/Sub Cntr Address City Lic Phone <br /> Billable PartyAddress City Zip Phone <br /> GIS Coordinates:X 3 Y "12'1,- <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <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 /> —0 EXTRACTION:Vapor/Water []HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _[]SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _EI SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION(Le Air Soame.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _CI OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING[INo[3Yes: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 /> #OF WELL($)TO BE DESTROYEDg OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: *W672 E �'TiS J&PRESSURE GROUT TODEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS to EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑ PIPE ❑MUSHROOM 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 applic 1'ornia laws // /� <br /> Signed ,(Q , -Q n Title/Company 14��6(, <br /> Print Name LAIGRIZ y S 1 R Date Y-7,11-10 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS /9 F" �/ <br /> WORK PLAN DATED 4-1)�(zU <br /> APPLICATION ACCEPTED BYAREA <br /> GROUT INSPECTION BY FINAL IN EC ION BY DAT U <br /> DESTRUCTION INSPECTION BY DATE U <br /> COMM ENTS/CO N DITI ONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHE K RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> Zgo2 $122: Z L� �y3y SR# D8`l� <br /> C04 <br /> W 3lvly 3 '��� (300 <br /> P # /?p <br /> 2900 77 0 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 FILE COW' PERMI APP <br />