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--Rek 6.• • SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 FIL IT <br />UNIT IV Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sjqov.orq/ehd <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 Joaqukn County Environmental Health Department. <br />Site Location17 1S t r" List Cross Street 1/4 11,1 EkTd LIA.J CIty/Slate3r;CKTed4. Zip '7511. APN 0 1,? Propon , <br />Owner K-4/ rea. tortz".4 A/4N7( Address / KA-/SCrJ.. P1-4'Zil- City/Stale 0 4K Lilm7Zip ‘Pf Ci Phone ft_f 53/0 <br />C-S7 Contractor tA-Lt) 1441-12-D Address 5-r0 anic K. lac) SIty/SlateA" Ye'r %Ell/0015 Phorbe 10/ 37'1 —413,,, Consultant/Sub Cntr PA 026 Address PI-6 EXP OA <br /> <br />, CIty/Statier407../9^Cuuc 7 37 ‘i iat Phone '1/4 <br />rI WS <br />Billable Party PI 4-o 2 k Address 6-4/41,g 4.1 AIJC V€ City/State Zip_ Phone <br />GIS Coordinates: X b33'1T-13.C)/ y 1-153/3-7, <br />CONSTRUCLIN WORK TO BE PERFORMED: <br />NEW WEL RINg)(CPT HYDROPUNCH, HAND-AUGER, OTHER) <br /> <br />23-SOIL BORING IDs OM 7, 41, s-, 6), 7 n WELL IDs <br />0 OTHER IDs <br />TYPE & # OF WELL/BORING <br /> <br />INSTALLATION TYPE <br />MONITORING <br />CI HOLLOW STEM <br />0 EXTRACTION Vapor/ Water 0 HAMMER/DR IVEN <br />_0 SOIL VAPOR PROBE <br />0 MUD ROTARY <br />1_.SOIL BORING p.PUSH POINT (GP/ CPT) <br />INJECTION (i e r SiDarge.0.?ono) 0 HAND AUGER <br />0 OTHER: 0 OTHER: <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE la <br />MULTIPLE CASINGS 0 MULTI-LEVEL VVELL CASING DIA: <br />CASING THICKNESS <br />DEPTH OF GROUT SEA177 t -3 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> <br />TYPE OF CASING: CI STEEL 0 PVC 0 OTHER <br />GROUT SEAL PUMPED: 0 Yes allo (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />GROUT SPECIFICATIONS NE k C <br />Y APPROX. BORING DEPTH f <br />PIPE <br />BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br />CONDUCTOR CASING C,1,,No 0 Yes: Casing Dia: Casing Deelh: Boring Dia: <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />0 OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br />0 PRESSURE GROUT TO DEPTH OF FT EIELOWSURFACE <br />0 EXPLOSIVES FROM TO FT BELOW SURFACE <br />0 MUSHROOM CAP AT (3 FT) FT BELOW SURFACE <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 accordance with San Joaquin County Ordinances, Rules and <br />Regulations, andArcable lifornia laws. <br />Signed <br />ALA A/ c fru n_ciye <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS 73 73 6.)e5-r <br />WORK PLAN DATED F1 PJL.zoi <br />APPLICATION ACCEPTED BY J. y 0 /4•PCL4 14/1 <br />GROUT INSPECTION BY FINAL INSPECTION BY <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 # <br />REQUEST PR # INVOICE <br />.Zetc5". S 125x I LI 3c? coctiviKA‘, If- -Z5---/-7, SR# 67091 <br />2,CtO -S Pc7 i- 4f5c).G RO # <br />(3500) <br />PR if <br />(2900) <br /> <br />AUTHORIZATION TO SIGN PERMIT LY ENCROACHMENT DOC Ai t? <br /> <br />EHD 29-01 5/09/12 <br /> <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />DESTRUCTION WORK TO BE PERFORMED: <br /># OF WELL(S) TO RE DESTROYED <br />WELL IDs: <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />COMMENTS <br />Print Name <br />Title/Company iOta aT4 r C a <br />Date c-/ 7( Cr <br />WELL PERMIT APP