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SAN JOAQUIN COUNTY UNIT 11 R ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehd UNIT IV WELL & BORING PERMIT APPLICATION ENVIRONMENTALII MVkLLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION PERMITISERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title,Chapter 9-1115.3,and 'the rStandards of the Stan Joaquin County Environmental Health Department. p Site Location N `I p pLQLNUIPrs Cross Street W SC44 HE' ��1 j City/State r#� C� Zip APN D 1"a�--}{� ProOwnerYy,i)? occ I fcFe1+1,-5 Address J -1 h d] �oC b/d 46 0 3 CasNrdow City/State n 1 Zip Phone C-57 Contractor Address 10 Ai( 1417 City/State /t.5'-w44 Lic 76 T3 d Phone 1/6 5`2 -a7b Consultant/Sub Cntr Address N rF4irc dem Dfc cC' City/State Skm.'*'kM is p `e"> Phone i k 9)2-711W) Billable Party Address 'N 20 City/State Do Phone GIS Coordinates:X Y PPRMIT EXPIRIED CONSTRUCTION WORK TO BE PERFORMED: NEW W ELL/BORING(CPT,GEOPROB ,HYDROPUNCH,HAND-AUGER,0rgnft may have expired withaut SOIL BORING IDs ❑WELL iniqnArt'391- ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTR I ea MOIR ' _❑MONITORING eHOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA- _0 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE �151resoIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soaroe,Ozone l❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: 11 ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ElAUGERS ElHOSE EYPIPE [:1MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 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 Regulations, all applica a Calif nia laws. / f f Signed Title/Company (>icc/`1 �f,hEPT/�ft�'Gt�'r�,� /try,l�'►�;kc Print Name mg rA I- Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED APPLICATION ACCEPTED BY /'1/) DATE ISSUED Z y' AR FZ 1J0 1) GROUT INSPECTION BY FINAL INSPECTION BY D� DESTRUCTION INSPECTION BY DATEECP- -_© COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# SAIV PE CODES 9 1 to T REMITTED CHECK# RECV'D BY DATE SERVICE R VI;;fv.L REQUEST +3 1 12I S SR# U U s Aq-4i RO# (3500 PR# (2900) , - C-5 .a;�N WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHME DOC EHD 1 5/09/2 LL PERMIT APFP- a: