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U. <br />• SAN JOAQUIN COUNTY <br />p0....fy, <br />ENVIRONMENTAL HEALTH DEPARTMENT LOP <br />• �" <br />J. 600 East Main Street, Stockton, CA 95202-3029R TON <br />Telephone: p L <br />Tele (209 468-3454 Fax: 209 468-3433 Web: www.sictoV.Orct/ehZ <br />q�iFiit+� <br />WELL & BORING PERMIT APPLICATION JAN 2 U 2012 <br />FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL <br />d?dAI� <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is maar Iri' <br />Joaquin County Development Title C�j ap�er 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. <br />/✓ems /— S1kU low_ !011e�mp- 7— ��v CIlX/�i4z q <br />Site Location Cross Street City �y Zip / S? /7 <br />7 APN <br />ProeOwner��� 74_ " •f Address At- V l City c1 f!%t.�� �� Zip � J Phon - ���` 7eJ <br />C-57 Contractor C�� IL ��-!%dress �� � city j��� Licf%�s�6^SPhon ���—S-eO0 <br />Consultant/Sub C9�. <br />_ /e Address 114ZlS- Ao0l ty - ����d UcA�Phone4�_Tk /A?tom/ <br />Billable Party �✓� Address I tIO L 1��44J�City .fT��j44" Zip % 52d� Phon •� ' �� 66 <br />GIS Coordinates: Y . <br />CONSTRUCTION WORK TO BE PERFORMED: <br />NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) <br />e19 Ej SOIL BORING IDs <br />WELL IDs X2.1 <br />❑ OTHER IDs <br />TYPE & # OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �,� 4 <br />MONITORINGHOLLOW STEM DIA. OF BOREHOLE ULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA: <br />eg <br />_❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS//C �^ Q TYPE OF CASING: ❑ STEEL�VC ❑ OTHER <br />_E1 SOIL VAPOR PROBE El MUD ROTARY DEPTH OF GROUT SEAL (0 TREMIE TYPE TO BE USED: P5 --AUGERS ❑ HOSE ❑ PIPE <br />_❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FU <br />_❑ INJECTION (i.e.AirSoarge. Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS 4,Q -E <br />_❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH Iq-5- r NOLTED TRAFFIC BOX OR STOVE PIPE <br />CONDUCTOR CASING ❑ No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: <br />COMMENTS: L✓EL L <br />lvl.✓ <br />L <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 FT BELOW SURFACE <br />TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ 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 prepared this application and that the work will be done in accnc wit San Joaquin CountyOrdinances, Rules and <br />Regulations, and all applicable California s. —91, ! _ L!/✓!L /�_E�� _ <br />Signed Title/Company s-"!'✓ �%O/fQL�i✓/��% ' �1"�� f�� <br />/ / ✓ZL <br />Print Name !^r may%/Cy G ���Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE SITE ADDRESS <br />WORK PLAN DATED V/11 112 - <br />APPLICATION ACCEPTED BY /f IA'fe"y I %f <br />GROUT INSPECTION BY <br />;zy." x <br />DATEssIS/SSUED <br />FINAL INSPECTION BY <br />�Z AREA <br />,'�" —DATE <br />DESTRUCTION INSPECTION BY DATE <br />COMMENTS/CONDITIONS: '�""/ �=`�` `� .Y �� �� � <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE <br />SERVICE <br />REQUEST <br />I RO # <br />PR # <br />INVOICE <br />$ 125 x <br />SR# eO irl i17, <br />RO # <br />3500 <br />PR # <br />2900 <br />C-57 WC WAIVER <br />C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />j�­ ,y/C� <br />2%23/✓ Z .� <br />