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-p <br /> o.Ag�'ly c • SAN JOAQUIN COUNTY -��l� �'\11 <br /> _. .--• " ENVIRONMENTAL HEALTH DEPARTMENT <br /> , �.SIE I ` "C P <br /> 600 East Main Street, Stockton, CA 95202-3029 gTolm T m-jl::A_TI'S <br /> �a..,. L,;,.•;c Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:www.s'gov.org/eh a M7u"'�''/I( EJ <br /> L(Fo'a� <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 Joaquin County`Environmental Health Department. .�r9 <br /> Site Locationgq"((:. W ��Q��Cross Street I Cco l I City S+CX 4V0 Zip 5� APNyo 7—1P0 OS� <br /> Propert l '7 -1 �n /�. cr/� <br /> Owner /171 tGt /II Address b ! E (✓4�1o0 City Zip Sd�� PhoneO'� %�� acv <br /> C-57 Contractor IXa • ,p�J1U, Address �7 City S�^ Lic Phone 6 J 9 <br /> Consult, <br /> Cntr a �_ t' Address 2 City S Lic 7•.Z Phone r�S�G�IYGY� S7�J-4S <br /> Billable Party UA✓1 Address (d City ip— Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: q I1r'yt/7 <br /> ❑NEWW#ELUBORING(CPT,GEOPROSEl�{YDROPTCVAND-AUGER,OTF)ER) n ,nV�/ /� L�`�II �u6r)(�/) <br /> SOIL BORING IDs "S 5(�I Jn r�.�4S US 3 df'f `71/1 4-' <br /> ❑WELL IDs <br /> ❑OTHERIDs <br /> TYPE 8#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> / u <br /> —E]MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE�'G7 /�❑MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA: <br /> �_❑EXTRACTION:Vapor/Water EIHAMMER/DRIVEN CASING THICKNESS !"1 TYPE OF CASING: 0 STEEL D PVC I] OTHER <br /> y <br /> —16 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEA TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _O SOIL BORING PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes 1,H1 No AXIMUM FyREE(�FALL I DEPTH IS/30 FT) <br /> _I]INJECTION(i.e.Air Soaroe Ozone)❑HAND AUGER GROUT SPECIFICATIONS SOr'1'cArl ��/W-'%I I'1 4V/ To 6 AAl <br /> —[]OTHER: ❑OTHER: APPROX.BORING DEPTTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS <br /> CONDUCTOR CASING LWNO 0 Yes:Casing Dia: Casing Depth: Boring Dia: <br /> : ///��\ <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 ❑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 FTSELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑ 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 Count r Ordinances, Rules and <br /> Regulations,and all plicable C fornix laws. <br /> Signed Title/Company <br /> PriV'r-1ari IVAdIlklae, Dale <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS N ND a-LJ e,A( c� 6 , <br /> WORK PLAN DATED b <br /> APPLICATION ACCEPTED BY DATE ISSUED of 1,6 Ll U AREA <br /> GROUT INSPECTION BY 113TtFINAL INSPECTION BY (J()II—(il.t.ltvl DATE °J /3 /d <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICO N DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 7-q05� $122. ( 7-2 .00 316Y-' SR# 6o <br /> RO# <br /> 3500 <br /> 7 ` C) 366.00 3f6y� zs o nS-345 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 WELL PERMIT APP <br />