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oQ4 J " c SAN JOAQUIN COUNTY ORIGINAL Q: ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.siaov.ora/ehd UNIT IV 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 three Standards of the San Joaquin County Environmental Health Department. Ct rY Site Location63r LA ' , ( yrlya 5TCross Street !' Ar 5 r CitytstateSTocktrr zip ZO Z APN ) 39 ) 6 5/C Property c• C ,¢ Owner 5&Aj6a.vvine0. lI ' �" 9ress 7r� � . l 4 ,SlyI.njor,,4 4r45rcity/State5r_o_e__kt zp `�SZl1Z Phonegy6E -3357 C-57 Contractor V In/ f Address 311a6Qr chcfl[9fnr xCC�' IateS/ I �iLLic .J9 Z S PhoeVe9 469 -7700 Consultant/Sub Cntr Co+ Address �=r.. nLVesTer -gCy/StateSGraek)F,tr}c ZOZG Phone ZO9)Z3`f�05fR Billable Party 6,, nOCr CUrlr 1 Address 18 � rrf .n � Wd4A Lr3r dy/State3foA7AnrZip7326Z6 Phone7-00f1Z3q-05/9 GIS Coordinates: X 63 '3 50 JY 2 1129 CONSTRUCTION WORK TO BE PERFORMED : 5ZNEW WELUBORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) ❑ SOIL BORING IDs Al IA/— 1 ❑ WELL IDs ❑ OTHER IDs TYPE & # OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS t_ ,MONITORING ('HOLLOW STEM DIA. OF BOREHOLE !a_j_._'I i ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 2 1 A . _❑ EXTRACTION: Vapor/ Water ❑ HAMMERIDRIVEN CASING THICKNESS 5tf-I�.�ffo� }}TYPE OF CASING: ElSTEEL PVC [IOTHER _❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL �rREMIE TYPE TO BE USED: AUGERS [I HOSE I] PIPE ❑ SOIL BORING ❑ PUSH POINT (GPI CPT) GROUT SEAL PUMPED: ❑ Yes id No (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION fi.e .PirSoarue. Omnel ❑ HAND AUGER GROUT SPECIFICATIONS A e A r Ce M e4& r qq lb s h t9 4 1 we rrr- _❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 1 r ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE COMMENTS: CONDUCTOR CASING*o ❑ Yes: Casing Dia: Casing Depth: Boring Dia:_ 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 ❑ 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 applliiccaab�la aalifornia I Signed Title/Company 5'enier6eo � �o}r"L�/CAdtr . f Th %r� �nalRg� e; Print Name IJ 11 I fr CSO n Z' Date JQ ' z_ 3 DEPARTMENT USE ONLY ,J SITE MAP IN UNIT IV FILE - SITE ADDRESS WORK PLAN DATED V U / 0/3 APPLICATION ACCEPTEDDATE I7,5EFA GROUT INSPECTION BY FINAL INSPECTION BY E DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE Rog INVOICE 'T O � � REQUEST PRO $ 125 x / :5 00 371 �y/,O� SR 00-7 S03 X00T'� (10 �� f 3 00 PR # 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP 1