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ORIGINAL <br /> >-P4 •!+�... SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> P.' <br /> SITE MITIGATION <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3147 Fax:(209)468-3433 Web:www.si4ov,Orgleh in <br /> in< IT IV p\\7�/ <br /> ••e 1 .. 'SFV#\� <br /> Lik"o'•�'' <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> APR <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 nC-ftt It ezo pf1@a with San <br /> i Joaquin County Development Title,Chapter 9-111 5.3,and the Standards of the San Joaquin County Environmental Heath Departmer;b ,� SRI s.)�( <br /> ,. � �73�� <br /> Site Location �ISu � cross street ra t'I-�- tnk city fUC zip t APN ��•(, . <br /> Property r- 7� <br /> Owner �`7 n '' G1/r Address 76� (r7 City �rit C. Zip Phone <br /> t C-57 Contractor.A t 1 �(�' I Address ff <br /> City St.Lr j Zrg4U Lie y�� Phon ? Y '1Consultant/SubCntr Address �iyi71 SCity !� Lic / `�G Phone � 'S7(JBillabb Party Address 7 SCity cc Zips Phone ✓ S�I <br /> GIS Coordinates:X-Y----- <br /> CONSTRUCTION <br /> _,- -_CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW W ELU13ORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) - <br /> ❑SOIL BORING IDs - - <br /> ❑WELL IDs - <br /> OTHER ID <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTpLEVEL WELL CASING DIA: <br /> ❑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: 11 AUGERS p HOSE ❑PIPE <br /> _❑SOIL BORING - ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No{MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _Q INJECTION 0.6 At OEM Ozone11HAND AUGER GROUT SPECIFICATIONS <br /> —[]OTHER: ❑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: ESTRuC"ON METHOD: C CK ALL THAT PPLY r <br /> #OF WELL(5))TO BE D€STROYED VER-BORE DIAMETER.O INCHES TO DEPTH OF I✓�' FT <br /> WELL IDs:�"1 1�'IRAhh ❑ <br /> OW-lU.(Y1N�-� PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATION U'U f [G, _ n �Cw4 ony FFA G L]EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERS LJHOSE []PIPE ❑MUSHROOM CAP AT CC3 FT) FT BELOW SURFACE - <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> 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 appli�/a�I-s�California <br /> Signed '�-- 6- Title/Company <br /> Pdnt Name 7 rll'o V) / Mph Date 'f <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNITIVFILE-SITEADDRESS -7fl--50- Tn <br /> WORK PLAN DATED ` d/ <br /> APPLICATION ACCEPTS DATE ISSUED v�/�d" AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# _ <br /> PE CODES FEE INFO AT REMITTED CHECK# RECWD BY DATE SERVICE RO# INVOICE <br /> M <br /> REQUEST PR# <br /> 'SOa $125X - aasbe 00 o �` /O�// SR# ec if <br /> PR# <br /> _(2900 <br /> Cz; WC WAIVER C-57 LETTER OF AUTI IORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> ERB 29-01 01/13/12 WELL PERMIT APP <br />