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SAN JOAQUIN COUNTY <br /> PQUIry <br /> LOP <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> H SITE MITIGATION <br /> • 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> �q•.- �P Telephone: (209) 468-3454 Fax: (209)468-3433 Web: www.sipov.org/ehd <br /> �lPORa <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. <br /> Site Location '/�E 1*/;;2F_ Cross Street $" S7(ra / City I Rte_! Zip 1:5 ,3 77 APN <br /> Property/' 1'97 Qa?. ��•� f jdLC/Ghl �)a�t)je <br /> per,Owner C -f Address r� 7-71 0G City _ Zip�SZ� Phon `7'r3C-57 Contractor RE (1ddress J/�� � Oct Ciitty/V�/1~�-Lic�J Phon7 1 -Xf4 <br /> Consultant/ rRr ��� G / Address��T�� sJ�R/�� kRy S�IDIf-Iqi �52,0Phone fl IYJA <br /> Billable Party ��Z A��sus 1 ylo �'W2veie ✓City f%�/�/&Zip Phon� 0-,?Wj <br /> GIS Coordinates:X Y <br /> S - r) <br /> CONSTRUCTION WORK TO BSE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> !WELL IDs <br /> ]OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE /a rr ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS 0 TYPE OF CASING: [ISTEELX PVC ❑ OTHER <br /> _[ISOIL VAPOR PROBE [IMUD ROTARY DEPTH OF GROUT SEAL -'A-F/ TREMIE TYPE TO BE USED:)R AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED Yes ❑No(MAXIM MFR FALL DEPTH IS 30 FT) �7 <br /> _❑INJECTION(i.e.Air Soaroe,Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑ TED TRAFFIC BOX OR t-$TOVE PIPE <br /> t VL �� CON UCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS:/� fU�c e /t l LT � I . <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> _j#OF WELL(S)T E ESTROYED ElOVER-BOREDIAMETER OF INCHES 0 DEPTH OF FT <br /> WELL IDs: /�/" PRESSURE GROUT TO DEPTH OF s^✓- FT BELOW SURFACE <br /> GROUT SPECIFICATIONS G EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERS ElHOSE Ll PIPE ❑MUSHROOM CAP AT(?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 prepay i application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all ap I•cabl or la laws. <br /> Signed Title/Company��� cJ���4��� ��/ /N�y � --sd2"V <br /> Print Name Date a /// <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY ,,//JJ DATE ISSUED AREA <br /> GROUT INSPECTION BY J//i�1'A/, I A--if^�✓� FINAL INSPECTION BY RF(`�11,.-_ DATE <br /> UU <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: ' — �•���� "� !/�� 2XI <br /> ACCOUNTING ONLY: AID# FAC# HPAI <br /> ENV�IRONM COUNTY <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST INVOICE <br /> $ les SSr g�(2 l.►3 ql? sR#00(o3 /� <br /> H 17� RO# <br /> 3500 <br /> PR# <br /> 2900 <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 />