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o.PavIN'•.c .SAN JOAQUIN COUNTY `r"' ORIGINAL 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 L%FpR WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION 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 Standards of the San Joaquin County Environmental Health Department. Site Location S+PCA...+ Cross Street&SfY;4-Ag!NA&Sf it tate SfMi4&% Zip 952010 APN 171 4008 Property Owner 1� Owner (-%1ity nS A i$+(-?GE(o Address 855 (A SfIlt,' 1#240 it /State ftZSA0 Zip 721 Phone S$'j-,jys-GyO t{ C-57 Contractor Grtebr;ik�Y S Address 550 4 WL 4a& Cit /State ��_� L,ic y8S 145 Phone `96' SIS-S� Consultan SubCntr6�COft^ Address 31100 601dt10 .�D�. aS�O if State,,,, Phone 91&-F57-ri1fY Billable Party I�CIM Address &66 6D(dyMIW AP.*R10 it /Stat4!n C O(Orbp Cf 5'74 2- Phone 91(v-M-911 R GIS Coordinates:X-12 o 0 u 1 if V.-S'6 Y 1-70 (. r U �7 gc(fS 4OM6 ) LAr —i2./ '/.480 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑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 _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) _2#OF WELL(S)TO BE DESTROYED / RSA ( OVER-BORE DIAMETER OF It INCHES TO DEPTH OF60 IS g1 FT /nw-IC PMW-let OW., _PO�AW'3�11W•( ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE WELL IDs:�tll� -iMbJ•(, GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: AU ERS ❑ HOSE ❑PIPE ❑MUSHROO CA AT(>3 FT) FT BELOW SURFACE COMMENTS G{JDGa1 (..v,4vL 9, NIrtN4.cL�)-nataLr�[I e�IQt,�GCLA S, (Qlls�'M2-911 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,Od all applicable Califo ni Signed Title/Company i Print Name Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 1/�D'1( ' S. 8 S T2�CT / 15CT er ryW WORK PLAN DATED o �LO/ APPLICATION ACCEPTED BY DAT AREA GROUT INSPECTION BY FINAL INSPECTION BY �CODATE -!8'7Lf DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST PR# Sotc� $125x 2Z 2n3O (ZS P78 52— 72T� 6-C7UK, - S-4"/�'� SR# � q v2 RO# 5U 375 3�� 3500 PR# 2900 C-57 ✓ WC t-� WAIVER JL) C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _VENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP