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ORIGINAL <br /> ogta.-tN.. SAN .JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> y � C ITIGATION <br /> 600 East Main Street,Stockton,CA 95202-3029 � J T <br /> Telephone:(209)468-3147 Fax:(209)468-3433 Web:www sidov.Gr", ^«� ( J <br /> Ctk'riP�` . <br /> WELL & BORING PERMIT APPLICATION iaF'F t? j <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED %4iaJll?ftP MF4iF1 )�i3 <br /> Application is hereby made to San Joaquin County tura permit to construct and/or install the wont described.This application is made injed"i 4Il�I�u� � <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environments(Health DZe-ptartment. <br /> jf,Ji 4 1/1{' � Cit U Zip.l.�>/� APN <br /> Site LOLBtIOnf�45 -116 E-L Cross Street (G Y <br /> Property 1`r/ �+ C.. �� Phone x'75 <br /> Owner fJ�i qq� ^GV'h ��r— Address (/ 70�i j11�7 t"!. City rpt Zp .�7�. <br /> C-57 Contractor t-tl� II �h1)'I, Address �7 city `7'('i7i er/�(/Cie j9 Phon <br /> City Y>Lic73G� .7 . phone KV <br /> consultant/Sub Cntr iAddress l 57(�T <br /> _ <br /> Billable Party Address 7 G t' Ci ly u- i2 Zip - 1 Phone <br /> GIS coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW W ELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER( <br /> SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLlBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _I]MONITORING - [IHOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _Q EXTRACTION:Vaporl Water ❑HAMMERIDRNEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _0 SOIL VAPOR PROBE O MUD ROTARY DEPTH OF GROUT SEAL .TREMIE TYPE TO BE USED: (]AUGERS ❑HOSE O PIPE <br /> _O SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:t]Yes d No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _I]INJECTION its Air Soaroe Ozonel❑14AND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: ❑OTHER: APPROX.BORING DEPTH. CIBOLTED TRAFFIC BOX OR ❑STOVEPIPE <br /> CONDUCTOR CASING❑No 13 Yes;Casing Dia: Casing Depth: Baring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED:, DESTRUCTION-METHOD- CHECK ALLTHATAPPL <br /> #OFWELL(S)TOBE DESTROYE,ID �/1 ,1^ /� �1., I, OVER-BOREDIAMETERor it, JNCHES TO DEPTH OF- FT <br /> W LLIDS; /'A!2;Q /r'�s�-'I"'� NG51�1: ❑PRESSURE GROUT TODEPTHOF FTSELOWSURFACE <br /> GROUT SPECIFICATIONS Cut U,i 11 EXPLOSIVES FROM 70 FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS U HOSE U PIPE n('., 1 ❑ "ROOM C1�'nT(>3�T FT BELOW1`d <br /> SURFnCE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> 1 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 a 3 lidp/pIs California laws. <br /> Signed t P 1 y A� Title/CompanyD�C' — <br /> Print Name T f 1 Vl <br /> ryryrr•�,,c�aa,�DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE DRESS ory....iJ T' r t'� <br /> WORK PLAN DATED /oZ <br /> APPLICATION ACCEPT B DATE ISSUED %2 AREA <br /> GROUT INSPECTION B FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID It FAC# <br /> SERVICE RO# INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# <br /> $125x /r rJ- 00 _4Z / 2 SR#Ro 11 <br /> �� _ <br /> 00 oZ (3500J�� <br /> PR# <br /> 2008) <br /> C-57 WC _ WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT __ENCROACHMENTV�O PFRI. IIT APP <br /> Elio 29-01 01/13/12 <br />