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q0 <br /> 1 7 <br /> PSAN JOAQUIN COUNTY <br /> .2_1 L I so <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 _F UNIT IV <br /> Telephone (209) 468-3464 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIONIUN 19 2013 <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 rll�8:6 in c'o mpl)iatnce with Sin"• H <br /> Joaquin County Development Title,Chapter 9-1 1 . and the Standards of the San Joaquin County Environmental Health Departmeni. i_._ <br /> Site Location IL777 ff W <br /> Property t�cross Street IF LOULeE city K Zip q5-3-_3';APN <br /> / Vj / <br /> Owner _:�v"(d Address 1,72 7 q,. City �-�r_00Q ZipAjj <br /> _ hone «!7. 58—2 <br /> C-57 Contractor 4P I Address pit 6VA11 city W. 15kt4is 138110 Phone <br /> Consultant/Sub Cntr kV_e-jI6_. Address k�j, 41 ity r0(4 12 kir, Lic Phone 2071 <br /> Billable Party Address q50 Alek--,A, I)scity Zip Phone 2071 <br /> GIs Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> [:1 NE ELUBORING(CPT,GEOPWBE,HYDROPUNCH, AND-AUGER OTHEF <br /> SOIL BORING IDS let ;Ll� <br /> Ej WELL IDs_ <br /> 0 OTHERIDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ,HOLLOW STEM DIA.OF BOREHOLE 3'1V� 0 MULTIPLE CASINGS C MULTI-LEVEL WELL CASING DIA <br /> EXTRACTION:Vapor/Water AHAMMERIDRIVEN CASING THICKNESS _TYPE OF CASING: 0 STEEL C PVC 0 OTHER <br /> SOIL VAPOR PROBE 0-MUD ROTARY DEPTH OF GROUT SEAL_a _TREMIE TYPE TO BE USED: [3 AUGERS El HOSE [I PIPE <br /> SOIL GORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:[]Yes [1 11 No(WYIMUM FREE F -I)EPTH IS 30 FT) <br /> INJECTION(i.e.Air Sparge,ozone)0 HAND AUGER GROUT SPECIFICATIONSod'f <br /> El OTHER: E]OTHER: APPROX.BORING DEPTH"-�—�. 0 BOLTED TRAFFIC BOX OR El STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING I�No 0 Yes:Casing Dia:_Casing Depth:_ Boring Dia <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 [:1 OVER-BORE DIAMETER OF - -INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:0 AUGERS []HOSE 0 PIPE ❑ 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 California laws. <br /> Signed 0,_al� U , (,_ Title/Company Set Er'MS-"r 4,P_-p.C)k _S <br /> Print Name pffy-\(Se R-- \1 k CV-F-N S Date (a I-t-5 12e I <br /> DEPARTMENT USE ONLY <br /> 4� -3 <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 94) <br /> WORK PLAN DATED A c4 Z <br /> APPLICATION ACCEPTED BY Yoh UHI DATTEI EA1 %F7`� <br /> GROUT INSPECTION BY FINAL INSPECT ON B <br /> E <br /> DESTRUCTION INSPECTII By��--, DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> $ 79qc.wtY SR# <br /> 325- 3 TPOV RO# <br /> (3500) <br /> PR# <br /> (2900) <br /> C-57 WC WAIVER Ala- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC <br /> EHDT9-01 07128/10 \/%fELL PERMIT APP <br />