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PgU1,N. SAN .IOAQU IN COUNTY • 'F`I L E .0 P Y ENVIRONMENTAL HEALTH DEPARTMENT OPC 1 970P LOP y: { • 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION •• UNIT IV • ,P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.SIaov orq/eh 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. I�t3 Site Location Alq Cross Street I 0 City/Stat (-pt Zip APN Property ~ ' Owner Address NCA lWiL 4L V�d, City/State r Zip Phone �-S j'i,Z- i I73 C-57 Contractor EC ►fir Address 9L,-% I,N;n pW. % Q, City/State Lic Consultant/Sub Cntr Address City/State o Lic Phone Billable Party S/r-\ Address City/State Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: f NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) .SOIL BORING IDs VIP - I IA 2'- Z UWELL IDs SV- I S�j - 2 WSJ-2.3 ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE .�,� " ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: -'VLEXTRACTION:Vapor/Water AHAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL 0,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 Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS r ❑OTHER: ❑OTHER: APPROX.BORING DEPTH .:35- ❑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) ST it OF W=;r( ) O BE DESTROYED b y r'H� ElOVER-BOREDIAMETER OF INCHES TO DEPTH OF FT LL IDs: l l�I IR P-2- S 11-% SV.Z 5V 3 PRESSURE GROUT TO DEPTH OF s5_3;I FT BELOW SURFACE GROUT SPECIFICATIONS PI k Wtg!- -k EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE I)4 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 a licable California laws. Signe Title/Company<=�({=� SCjtq-vi.ti\} YyE�,t Print Name �Qs Date 12I I )p DEPARTMENT ,�USE ONLY �� SITE MAP IN UNIT IV FILE-SITE ADDRESS ��! 1 �� rfyl 711�(/�Tb-v.A WORK PLAN DATED i361z APPLICATION ACCEPTED BY DATE IS /4 GROUT INSPECTION BY FINAL INSPECTION BY ,, ......�.••r-i— �E /-G-�S 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# 5^ $13o x 1 13b 5 0$%552.- Lr4 ui ' SR# 0 IdA Z I J U 3 00 PR# C-57 WC WAIVER NH- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _/ ENCROACHMENT DOC ,t/' EHD 29-01 7/24114 WELL PERMIT APP A-(Z.DO 41 !o 2-4-1