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SAN .JOAQUIN COUNTY y� EN,,RONMENTA HEALTH DEPART N LOP ILE COPY E MITIGATION 600 East Main Street, Stockton, CA 95202-30 9 UNIT IV �4ii=oR �P Telephone:(209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.orglehd WELL & BORING PERMIT APPLICATION l�. 12nuj FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1_ 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�pfn*lvelopment Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Heakh'Department. tt 2N. 'AL, n /SiteLoM 3 Cross Street City�T is-TpI• Zip x[5204 APN t.0��, Fkj PropertG,Owner ` bFJAddress i-i_Z� r!- !.G -70r-J Zip X202Phone -f C-57 Contractor Address;?F(o57/'j a4�A?�I �{ City I Lic �-3L,_2'?ZPhone�2�, 'Mo�;—J'2If ConsultanUSub Cntr:�"rr-i E71`, 66;FAddres5 ., r0, GLic GS?` 77Phone o7�- f-5 !5'-i , � Billable Party_ TiLL Address City Zipg58'-F 3 Phone k GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑ -NEW (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE 8#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING [I HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DEA: ' _C]EXTRACTION:Vapor/Water [IHAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: !]STEEL [I PVC Elv OTHER ` _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _E3 SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i-e Air Soar¢e.Ozones❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER; APPROX.BORING DEPTH ❑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: cHECKALL rHArAPPLY #OF WELLS)TO BE DESTROYED ` OVER-BORE DIAMETER OI 6�I INCHES TO DEPTH OF�S�s� WELL IDS: ^3J 5✓` f 7. S ?~ (�5 PRESSURE GROUT TO DEPTH OF 71-55_ Fr BELOW SURFACE GROUT SPECIFICATIONS Sm/C7 Q f4z_6 EN-T— '❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE X PIPE OMUSHROOM CAP AT L3 FT) 3 FT BELOW SURFACE COMMENTS M lJ — 75 g r 0 A 5(l 'E 2✓•r-E U,13, I(IE 7 Gv lt_ MtV-3 /tfrc/—S , 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 appficable California laws. Signed L/ p Title/Company ��/'L ��•/✓4 i<✓� ,2 } ";<��LC ��.+f rlGr Print Name �� 'hr . C 1�� A C—LI Date i DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 2-3V5 WORK PLAN DATER • ri-2.6 if APPLICATION ACCEPTED BY t I AREA�� ► f GROUT INSPECTION BY FINAL INSPECTIO DATE DESTRUCTION INSPECTION BY Dom+" DATE —T T COMM ENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# f PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 3503 3 37S Roo b or C-57 WC WAIVER V C-57 LETTER OF AUTHORI TION TO SIGN PERMIT ENCROACHMENT DO EHD 29-01 07128/10 WELL PERMIT APP