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-GENED o�q�Ly. • SAN JOAQUIN COUNTY 46 APR 2 5 201' •�.F+r'••p . -ENVIRONMENTAL HEALTH DEPARTMENT LOP OITIGATION 600 East Main Street, Stockton, CA 95202-3029 ENVIFONIMEN�Aj�r •.- r' Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siaovfarW SFPVlf SNIT IV WELL & BORING PERMIT APPLICATION nolGINAL FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDI NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a pennit 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. ]-1 Site Location )-I S r On VW 7 • Cross Street .1 ClC�SOr1 City C 6400 Zip �� APN I"l 1'160-03 Property {{Il 1111 1 ' .1- Q p ' 2/'V, 9is 9�5�$ Owner r�lun(XO 11Rh-a.I.1PT�-t• Address �-OI fJ, n S 1 City 5`7OC-f 404) Zip o�o �"vPhon rA - cr C-57 Contracto 11 11r Address }.YS Pq1-� L� 'A CRY ��^UfO'n•I®^ Uc$�o CJ Phone'11L Consultant/Sub Cntr G� Address }7 S v1L� City L1f 2T�U,6��/iii�0rrr�� ,y2 Phone [b 5711 9 Billable Party Address 7 cv' City h Zip Phone ?"c/ GIS Coordinates:X 2,7tj40 Y t11/}g CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) SOIL BORING IDs WELL IDs (7Z- ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICT A� 11 _❑MONITORING HOLLOW STEM DIA.OF BOREHOLE q 0 MU TIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS--TYPE OF CASING: ❑STEEL PVC ❑ OTHER _I]SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: OrAUGERS ❑HOSE 0 PIPE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED.`oYes ❑No(MAXIMUM FREE FALL DEPTH IS�q,FT) INJECTION(I 4 para o wel 0 HAND AUGER GROUT SPECIFICATIONS Q I 41-0 + � 1 I Y q .' ) I t CPmtn'r ❑OTHER: ❑OTHER: APPROX.BORING DEPTH -70' 'Y ' / P<BOLTED TRAFFI BOX OR 0 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 WELUS)TO BE DESTROYED El 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 applic le Ca ofma laws. /�! Signed Title/Company — Print Name Oy-1 AA I ayi Date �Z DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRES �a�O/ r- WORK PLAN DATED APPLICATION ACCEPTED Y DAT SSUED l'/.�1J AREA GROUT INSPECTION BY FINAL INSPECTION B DAY DESTRUCTION INSPECTIO�'I��..ggY DATE _ COMMENTSICONDrnoN§e"r- _ ' / 'a O ACCOUNTING ONLY: AID# FAC# SERVICE RO# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PRO INVOICE $125 X o � OCO. 00 �'� SR 7.2 Jam•O.'� 8 ,�7. .35�� OOlwuie�JJ PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD29-0 01/13/12 WELL PERMIT APP