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o "`'I" SAN JOAQUIN COUNTY j <br /> N:•' .•�{ ENVIRONMENTAL HEALTH DEPARTIVItNT - L <br /> •' 1868 Hazelton Avenue, Stockton, CA 95205-6232 (319S MITI 'ATION <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.s' ov.or " I <br /> �/FOR <br /> u � Y �� <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDI I IOC'5 2014 <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 a licatlionN�l <br /> Pp frUra�Ift,San <br /> Joaquin County Development Title, Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Dep AIT/SERVICES <br /> Site Location I sa V- *06In-� Cross Street k/- 105� I� ,� <br /> City/State�` A Cec r Zip 3 APN a00"I'I o`0 a <br /> Property f\ <br /> Owner LfAul &�A57CA Address I"AMF City/State Zip Phone�JaOcf• ��5'M <br /> C-57 Contractor ��x SCar1e /�ri�ti�lyAddress 000 U LLI-t- Stier City/Stacte•�Crc`� G`��i -OF//cc �/O Phone?it,-6 <br /> Consultant/SubCntr_ INC- Address 4 T 'I?- u Cr;City/State� 5 Lic P6�$�b�-V Phone <br /> Billable Party Address City/State Zip Phone <br /> GIS Coordinates:X 27,29P75�!- Y —01, �25�7/zll <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> 2'NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑ SOIL BORING IDs <br /> 2 WELL IDs /if K/ ­2 Al fit/- Fa Al W <br /> ❑ OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING q HOLLOW STEM DIA.OF BOREHOLE Pr ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: G`+ <br /> _❑ EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL a-, VC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 32 3TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE .9 PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED: ®-Yes ❑No(MAXIMUM FREE FALL;DEPTH <br /> _❑ i <br /> IS 30 F✓No S�7K�INJECTION(i.e.AirSoarae.Ozonel❑HAND AUGER GROUT SPECIFIC �" <br /> �� <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 105 5�� :20 e ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING.UrNo[3Yes:Casing Dia: Casing Depth: Boring Dia: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS V-/— <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 FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORK NGI DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify thatt ve prepal dd this application and that the work will be done inaccordance with San Joaquin County Ordinances, Rules and <br /> Regulations,a Happlicable'Cali orrna ws. <br /> e <br /> Signed " citt Title/Company <br /> Print Name Date <br /> _` DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS /� ?'? <br /> WORK PLAN DATED (i f / 2rxco7� <br /> APPLICATION ACCEPTED BY DAT AREA %(e <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE q -t 5 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> C ^� 2 Q <br /> REQUEST PR# <br /> $ 125x / J7 ( e1=1Ct -ZR -/ SR# <br /> 2C(O� RO# <br /> (3500) <br /> PR# <br /> (2900) <br /> C-57 WC ----_4,,:�(IVAIVER -C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT !-ENCROACHMENT DOC 'vim <br /> EHD 29-01 5/09/12 <br /> WELL PERMIT APP <br />