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s �0?L SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, CA 95205-6232 SITE MITIGATION Stockton, �q• _' r�;:P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/eh P �,� ��FOR WELL & BORING PERMIT APPLICATION RECEIVED FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATI( WV 0 4 2014 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOACIUIN COUNTY Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made Joaquin County Development Title,Chapter 9-1115.3,and the Standards of thee San Joaquin County Environmental Health Depart) L Site Location i�l I t>/y�C a' `•� •/`C'ross Street �s`t l� `�t Cit /State 7�L U 0 y `� �� Zip AP Property .i ��. _ Owner �� U�Z�U {{Ad��dres U? I )��/ 'r� ot'f ✓ City/State 4�'J�Zip q Phone D%t 2r'`_ C-57 Contractor J WABdress" q,061�DVL tk IDt City/State S_Wlb�' Lic�Phone 7y111-14T!" � Consultant/SubCntr Address City/State )-Wz',AMLic Phone I Billable Party Owye-, Address City/State Zip Phone GIS Coordinates:X 37.C177L(9 Y -(2r. .Z.50 S CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs eV✓Y�'C r / y i!' _Di R 1'/ fp, I 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.AirSoarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE 11 CONDUCTOR CASING❑No[3 Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: M W-3 .-I, OJ��'G�I'I NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY #OF W%(S)TO BE DESTROYED t [OVER-BORE DIAMETER OF INCHES TO DEPTH OF ' FT WELL IDs: / 6T Ca'PRESSURE GROUT TO DEPTH OF V6- FT BELOW SURFACE GROUT SPECIFICATIONS ( a i t1'( ':-j [:1 EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TQ�BE USE AUG RS [__1 HOSE, PIPE l�MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS �"1w� 1�/✓ ✓t E' �l 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I herebycertif that I have pr ared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulation nd ail applic lifornia laws. Sig r Title/Company Print Name Date 106? Qf" DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS jQ1( M( BRa*CDGJ4&f /gam S AV KT0�!l WORK PLAN DATED _I'3Iuw9IL5 9 1 C- .,V^ 7.•.��-,-.,.e.....,,.. APPLICATION ACCEPTED BY -s -yo 0K L4,f4-1 DATE I J'ij�c• rl �r �4 AREA. GROUT INSPECTION BY FINAL INSPE TION BY D4TF�" —I' DESTRUCTION INSPECTION BY DATE #-72-C—/ COMMENTS/CONDITIONS: S S ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# $130 x 3 ?S . — 1=4 SR# 70gZ 2 2_ab3 3q Q R50o R# P J(2900 C-57 y WC 1/ WAIVER po,;L_ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT I— ENCROACHMENT DOC EHD 29-01 7/24/14 WELL PERMIT TP