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Ry. 28 .2015 01 : 42 PM Sweet Leaf Hydra 20„ G00 ��° E ” PAGE. 2 I r SAN JOAQUIN COUNTY fulAY 2, ENVIRONMENTAL HEALTH DEPART E T LOP < :J " �r , 1868 Hazelton Avenue, Stockton, CA 952D5-6232= r`lr�c� , , e r�flu ri1lt' r cqr rroPN`P Telephone: (209) 468-0343 Fax:(209) 468-3433 Web:vJMrw.slcehd.coni WELL & BORING PERMIT APPLICATION ED FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION JUN 0 8 2015 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED R` �Gf""` Applivahon Is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in clolV-,chll WW HEALTH Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department Ir/SERVICE$ Site Location 2L (' N >>cc lrt V'-,t Itit Cross Street Etv i ICily/Sta(e Li",I.li C 14 Zip APN OLI R-O Sp-3/ Property �r Owner �I ,-i 4.11i4 hl i•i• arh• L I'.b t Atldress _._-___ City/State 'Lip Phone C-57 Contractor i,cul„_n..d 0:�N,' Address cjSU lZ�ocr ILd City/Stale WYfr (t is -f ICC•7r1 Phone -lC-7 7 7y-y3Cv' COnsultamVSub Cntr Address CIly/State l��i--1e1 Phone Billable Party )r.•,r,T Vic`tdg:;tc(•� — Address 44�C t`1o,.t4ce(l tic\l `J+-CitylStatel'lIC(aro,rtLlp Phone -zL' - '-ttjj— GIS Coordinates:X Y •CyONSTRUCTION WORK TO BE PERFORMED: t "i' NEW WELLIBORING ICPT,GEOPROBE,HYDROPUNCH.HAND-AUGER.OTHER) ,19 SOIL BORING IDs�IJ� ❑WELL IDs b'I O) ) SD ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS y'Q- 30 _❑ MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE _ ❑MULTIPLE CASINGS I]MULTI-LEVEL WELL CA; C & —❑EXTRACTIONVapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING' ❑STEEL I]PVC ❑ ISIC,t•l.(,- _❑SOIL VAPOR PROBE ❑IdUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED EIAUGERS IN SOIL BORING ❑P'JSH POINT(GP/CPT) GROUT SEAL PUMPED'❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 F TI JJECTIfN( amaO+or❑HANG AUGERrI" __C) mi � _001HER J9 OTHER:TlVAto!NUI, APPROX BORING DEPTH ❑BOLTED TRAFFIC BOX O S R 7 Z 7 O W Y C o I W- \6 W- \ CONDUCTOR CASING❑No O Yes Casing Dia Casing Dal �•� COMMENTS: 1r c V( l 11 l% b rf O r V NOTE�TE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PE r //' DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY I b(I 1+p CF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEF ` /JELL IDs: ❑PRESSURE GROUT TO DEPTH OF GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO r TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑ PIPE �— COMMENTS ❑MUSHROOM CAP AT(>3 FT)_i / 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTN I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin County Ordin Regula ns,and all applicable California1laws. Signed r_C I La jot.- LQL( i I i� 1�' Title/Company 1Jyy.t 1 ) A Wuia i)(u A D1 t V� I l'l; Pant Name (�� (t`�11(I �. \U(`L X11 4'('U /'� Date 1`S DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SIT A DRESS I2 OC7 NR C,,l._w�u vi - Z\ WORK PLAN DATED S�JS APPLICATION ACCEPTED BY ' ,I� t /y�pG�-- DATE ISSUED G Lr 7 T AREA GROUT INSPECTION BY L&AAA't' em•-•— FINAL INSPECTION BY LZtrit� -1 DATE b f q 7•S DESTRUCTION INSPECTION BY DATE COMM ENTSICONDITIONS: I" )D - S <. ACCOUNTING ONLY AID# FAC it p SERV RO 11 PE CODES SEEDINFO AMT REMI ED CHCEyCK# • RECV'D BY DbTts rs/ REOUIEST PR#_x_13 "vo1cE ;T SR# PJ0f2•{6 A "Ito 3 3`)0•- l 3y0•00 00I-z,46y ! (2900) 52ZoIS — C-57_x,_ WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC