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ORIGINAL <br /> SAN JOAQUI ICOUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP i <br /> I <br /> i <br /> 600 East Main Street,Stockton,CA 95202-3029 SITE MITIGATION <br /> TeM-Phone.(209)468-3147'Fax:{209)468-3433 Web.'www.sigcry:orrateh Val <br /> WELL & BORING PERMIT APPLICATION <br /> raa <br /> ` . <br />{ FOR WELLS AND BORINGS USED FC1R Ct�NTATUIINAN7 INVESTIGATIONS AND REtViE01ATION <br /> r 10WREFUNDABLE PERMIT'E7tT'1RES t YEAR FROM C}ATE ISSUED APR ` i f� <br /> Application Is hereby made to San Joaquin Carty for a permit to Construct andlor install the work described, This application is> �� with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environ tneritat Health Departmer i <br /> I r� l h Dept} <br /> SiteLocation d[ ? Cross Street; I`G O,l Clty ' tG' Zi 53 ( ,,CPN <br /> Property - P <br /> Owner G V Address _ C4 ` hit dZlp� Phone$35-45 <br />' C-57 Contractor A11- UA- , Address �r City&4f ' rjtr Lie 2VM f <br /> ConsuitantlSutsCntr ,_,� AddressCity Lie Phone <br /> BittatsteParty Address City Zip 9'-> Phone <br /> CIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: � <br /> [I NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH:BAND gUGER,{?1NEt?} <br /> SOIL BORING IDs <br /> ©WELL IDs <br /> Q OTHER IDs: I <br /> TYPE&#OF WELL(BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _0 MONITORING C3 HOLLOW STEM DIA,OFBOREHOLE 0 MULTIPLE CASINGS❑F'ULT&LEVEL WELL CASING DIA: <br /> _O EXTRACTION:Vapor/Water )].HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 04 EL 0 PVC ❑OTHER <br /> _[I SOIL VAPOR PROBE ❑MU.P.ROTARY DEPTH OF GROUT SEAL T-REMIE TYPE TO 3EUSED:.t]P:L GOt^.r p HO$E Q:PIPE <br /> _EI SOIL BORING (0006 POINT(GP[CPT) 'GROUT SEAL PUMPED:Q,Yee ❑No(MAXIMUM FREE FALL DEPTH IS 30 FTI: <br /> ,_,©INJECTION(to AirSparga Ozonel[3"AND AUGER GROAT SPECIFICATIONS j <br /> —0 OTHER: ❑OTHER: APPROX,BORING DEPTH [Q BOLTED TRAFFIC BOX OR <br /> PIPE: r <br /> CONDUCTOR CASING[I No Q Yes:Casing Dia: Casing Clepth.- bok N TSIs ... <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED.- ESTRUCTON METHOD: k ALL THAT APPLY r <br /> �#OF WELL(S TO,BE D STROY ED VER-BORE DIAMETER O INCHES TO OEPTHOFjFT. <br /> IDS:C Ica "1 elf' ]n OLS+ Ili w�"' El PRESSURE GROUT-to DEPTHOF _____ _ -FT$ELOW:SURFAcE <br /> GROUP`SPECIFICATION t:c ':. � avt G?: ©EXPLOSIVES FROM, TO FT SEI.OW$URFACE <br /> TREMIE TYKE TO bE USED: AUGERS HOSE PIP <br /> - .. . I.}. (�MUSHRbC)M CAP ATr(?SFT) FTBELOW'SURFACE. <br /> " <br /> .:COMMENTS } <br /> S WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)?OR INSPECTION APPOINTMENTS: <br /> 1 hereby certify that I have prepares this application and thatEtte work will be done In accordance with::Sar1 Joaquin County t3rdinances,ttlewAnd �. <br /> Regulations,and all appir ie:Caitfor111a ws' <br /> SignedTitleJCoinpany` U <br /> Print Name <br /> -----Pate `1 7 7X <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT!V FILE-SITE ADDRESS <br /> WORKPLAN'DATED / ./ <br /> • "h <br /> APPLICATION ACCEPTE DAT $ eG/ir <br /> ---AREA p <br /> GROUT IWSPEO TION B`f ...: AL INSPE 10DATI= <br /> V4� <br /> DESTRUCTION INSPECTION B . ATE ; <br /> COMMENTSICONDITIO)NS. ` 7FAdd2 <br /> k <br /> v <br /> ACCOUNTING ONLY*:. AID#. FAC °'N^wI"C <br /> PE CODES, FEE INFO AMT.'REMITTED CHECK# RECI%'D BY DATE S CE RO# INVOICE <br /> REQUEST PR# <br /> ' $,725 <br /> clio. Rt7# <br /> 177 7-1 <br /> PR.# <br /> 2$40 <br /> WC WAIVER .. C-57'LETTER OF AUTHORIZATION TO SIGN(PERMIT ENCt2Di4QHA+tEIIT DCtG I <br /> EH0.29+01 011/73112 _ :_r R•.: WELL PERMIT APP <br /> I <br />