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pP4VIN•.,c SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP < w Zi SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 UNIT IV •., ;� Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/eh ;li'6 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. Z 7 Site Location !OH �I11 4ri� ` I Cross Street City I C6' Zip953-7( APN Property Owner La�S Ian Address Dy I.v C f� City f� Zip 5'3Phon D --?60 X C-57 Contractor l'<(,EAddress 7 City n Lic ko)2 Phone do Consultant/Sub Cntr AC,,% Address City $ L Lic ?Phone ll- 300 Billable Party A 66 77 Address � R City S+QC +V�) Zip Phone 8I,TU tb GIS Coordinates:X N;5g7Y �� `�k 1`1�(35 CONSTRUCTION WORK TG BE PERFORMED: ORIGI A❑ NEW WELL/BORING(CPT, EOPROBE,HYDROPUNCH,HAND-AUGEFj,OTHER) SOIL BORING IDs �1S I� }�fo't� ^ D I� WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 1� / _E]MONITORING El HOLLOW STEM DIA OF BOREHOLE ❑MULTIPLE CASINGS[IMULTI-LEVELWELL CASING DIA:/L' _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: [ISTEEL [IPVC [IOTHER _E3 SOIL VAPOR PROBE [-IE MUD ROTARY DEPTH OF GROUT SEAL 04I 11re TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE PIPE ❑SOIL BORING ]PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑/Yes No(MAXI UM FREE FALL DEPTH IS 30 FT) 11 /� EiINJECTION(i.e Air Sparge Ozone)El HAND AUGER GROUT SPECIFICATIONS h p r��G r �P!✓h�l� t 6�616,� n1�/ _❑OTHER: ❑OTHER: APPROX.BORING DEPTTH/ �� ❑BOLTED TRAFFIC BOX OR [I 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) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT TO DEPTH of FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: [:]AUGERS ❑ HOSE C-] PIPE ❑ MUSHROOM 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,and all applicable Galifo,rnia laws. Signed Title/Company Print Name n /Vt ( C' Date l " DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 104 'Baverly f l Lice- WORK r 2 3 2012 WORK PLAN DATED J g 6.z D 2 2 -/ APPLICATION ACCEPTED BY ,G i C C e DATE ISSUED ENVIRONMENTAL EALTH 1459 GROUT INSPECTION BY 1 C+&r4'A M u td4l FINAL INSPECTION BY V7c-"7,, rJ,L TSA `2'S.13 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: a Z B" -I `I ,e,6Rf—, CyxOx ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST I PR# .SQ s $125 x 00 3 5 G 8 / -.Z -l2 SR#9V, S 98 Z- 3S0 3 3 vo3 17 S ad Roo) G I S PR# O 0 (2900) C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 01/13/12 WELL PERMIT APP