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I� <br />�o�g•.�o SAN JOAQUIN COUNTY PAYMENT <br />.yy ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED—LOP <br />N < <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 - .3 U 2AY MITIGATION <br />•. UNIT IV <br />Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.siaov.ora/ehd <br /># JOAQUIN COUNTY <br />WELL & BORING PERMIT APPLICATNNVIROMENTAL <br />FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONeJ&IbTKWikbWI9*NT <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 J(� S'cOwL ` l`'C71fss Street �iG�� City/State Zip 45 APN ��-03D" (D <br />ProperOwnertyr, D�dil 10 ?`.i� 6.iL� <br />Owner dress r- -G� City/State Zip Phone <br />C-57 Contractor 1^ N0RE Address 33 3 hiTf-4c rte. city/Stat 95-447- Phone 9i6-939-y117- <br />Consultant/Sub Cntr Address City/State Lic Phone <br />Billable Party�S Q9FML5M Address .b Box Z3Zot1 City/Stateej, / gNr�YJp Phone 9Z -S - UID -11LO <br />GIS Coordinates: X <br />Y CA <br />CONSTRUCTION WORK TO BE PERFORMED: <br />�DIEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) <br />❑ SOIL BORING IDs <br />❑ WELL IDs <br />❑ OTHER IDs <br />TYPE & # OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />_❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE ZN ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br />'EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC jq OTHERL <br />_❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />_❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />_❑ INJECTION (i.e.Air Sparge, Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS <br />_❑ OTHER: XOTHER:Clim— APPROX. BORING DEPTH Z4 C'I'O 6.5 ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />COMMENTS: T <br />�L- CONDUCTOR CASING < No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: <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-Y110RKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />certify <br />Signed <br />Print N <br />this application and that the work will be done in accordance with San <br />SITE MAP IN UNIT IV FILE`- SITE ADDRESS <br />WORK PLAN DATED j___ <br />APPLICATION ACCEPTED BY _ <br />GROUT INSPECTION BY A <br />DESTRUCTION INSPECTION BY <br />COMMENTSICON DITIO NS: <br />Title/Company <br />DEPARTMENT USE ONLY <br />County Ordinances, Rules and <br />DATE ISSUED `/ e f/13 AREA <br />FINAL INSPECTION BY � 4Y .-fie �7 ZDATE <br />DATE <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 />RO # <br />INVOICE <br />REQUEST <br />PR # <br />)' / <br />i y'7 l <br />$ 125 x <br />y <br />�!� <br />SR# 00 ,707 <br />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 5/09/12 WELL PERMIT APP <br />