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IyUU-15-2012 15: 18 ENGEL) INCORPORRTED 1 925 esisry .01/03 <br /> 4 `ry • SAN JOAQUIN COUNTY • F I� E PCOP Y <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 ,T I IGAT <br /> 40 Telephone: (209) 468.3147 Fax:(209)468-3433 Web:www.s' o . <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIf FM 1 6 21112 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS%1ED <br /> Application is hereby made to San Joaquin County for a permll to construct andlor Install the work described. This application Is9,hNhE9A4dlgN>`2@IdhtT$an <br /> Joaquin County Development Tille,Chapter 9•1 115.3,and the Standards of the San Joaquin County Environmental Health DelcWtO EENVIRONMENfAL <br /> aE�Sita Location J oobLuaT�- _ city/StateAn{9, HEALTH�� rAP <br /> Property <br /> 05- <br /> 3110 D44 <br /> Owner Address r4 sd.r C14,1state JCR <br /> ZIP 9y Phone r- 9- �I� <br /> C-57Contra or �f�lift' Address 391)6 �U[lc�r D City/States Liu-420504F phone �U4- V - OD <br /> ConwitantlSub CnV tjC760 Address . MiIA,, ANAe City/State R'PE fI Lic n+IA Phone 20q-321-2000, <br /> Billable Party Address City/State Zip Phone <br /> GIS Coordinates:X Y <br /> C NSTRUCTION WORK TO BE PERFORMTtJ: <br /> NEW WELL(BORING(CPT,CEOPRO13E,HYDROPUNCH,HAND•gUGER,OTHER) <br /> SOIL BORING IDs 5- 1 •fo .C"1 O <br /> I]WELL IDs <br /> ❑OTHER 105 <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTIsN SPECIFICATIONS <br /> _0 MONITORING HOLLOW STEM DIA.OF BOREHOLE <br /> ❑ / C3 MULTIPLE CASINGS[3 MULTI-LEVEL WELL CASING DIA; <br /> I <br /> 9_14 EXTRACTION:Vapor afar I]HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL (3 PVC [I OTHER o <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL y TREMIE TYPE TO BE USED: ❑AUGERS E3HOG;—C-1—PIPE <br /> 10gO SOIL BORING X PUSH POW(GP CPT) GROUT SEAL PUMPED:0 Y" I LNQ(MAXIMUM FREE FALL DEPTH IS 30 Fr) <br /> _L3 INJECTION 11 a ArS,p,w.D9a9113 HAND AUGER GROUT SPECIFICATIONS N• --k ` pm-lr- 1` <br /> _0 OTHER 0 OTHER: APPROX BORING DEPTH, 1 'Zr 1 _ 0 BOLTED TRAFFIC BOX OR D STOVE PIPE (� <br /> COMMENTS: CONDUCTOR CASING Q No CI Yes:Casing Dia: Casing Depat__,_,__ Boring Ola: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK Au THAT APPLY) <br /> _#OP WELL(S)TO aE DeVkOYED ©OVER-BORE DIAMETER OP INCHESTDOEPTH OP FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS 0 EXPLOSIVES FROM TO Fi BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS 0 HOSE El PIPE []MUSHROOM CAP AT(g3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby certify t I have p ed this application and that the work will he done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, lappllca allfomla laws. �1. / <br /> Signed !-M <br /> Thle/Company . / Gn)LYL" <br /> Print Name 9r,hna/2 M& O Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS56(9' E. 6)06DIV19rz A AUG - /;w0-%&t,? <br /> WORK PLAN DATED OC C- �. Z. <br /> APPLICATION ACCEPTED BY J . yofBKL4.w - _ DAT AREA <br /> GROUT INSPECTION BY _ ___.._.. FINAL INSPECTION BY DATE /?.r •/Z <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTSICOND ITIO N5: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> 1P900) <br /> EQUEST PR# <br /> R# <br /> 240 O# <br /> 75 R# <br /> C-57 •„ WC _JL WAIVER YJIP - C57 LETTER OFAUTHORIZATON TO SIGN PERMIT (/ ENCROACHMENT DOC <br /> EHD Z9-0t 5169/72 WELL PERMIT APP <br />