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SAN JOAQUIN COUNTYFILE C ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION UNIT IV �;•.. ' Pi Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: �:wvj.s;gov.org/ WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JAN 2 2 201-3 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`Le"?'e.;z�rf- t �l i i Site Location�CC 'Vrq V 1 C� ✓� Cross Street T, 11, L('vQ ( � City/State St-cV jun Zi _:t_26 FEf34 Pl3; . Property `/" rrr I t- I Owner ]-(,hl AddressC4 1 F �I� �I`-_�� S f r C O it City/State -<<)I I Zip` $ b 5 5 Phones C-57 Contractor C +II Address�i S 6 N c Ave City/Stated j I nr 7 Lic`t 5-1 G5- Phone Y�s-- 313 "S c C ConsultanUSubCntr rilS- E Address is �l�t� P, l< 1r,J ,or-3city/States4<cu'77ei�tic P11' Lf Y 7 Phoneyt� S�j c5-7C Billable Party Address City/State Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: }"IL ❑ NEW WELL/BORING(CPT,GEOPROB ,HYDROPUNCH,HAND-AUGER,OTHER [0 SOIL BORING IDsC=Rnl; C(;uju;�� r�/�e��✓� � �c-lf� 12. C—) 'L"E ❑WELL IDs ❑OTHER IDS TYPE&#OF WELUBORING 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 -2L-0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE 10 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(Le.Air Soaroe Ozone)❑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: (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 pJoa9uin Count Ordinances, Rules and Regulatio ,aand all applyable California laws. * C t c E 1 S 1 Signed vim, f V Title/Company F-C L C T S f v/✓_i, j v` Print Name �c h�'r^'� F��(fG ✓1 Date '1CnJ=lY DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 241D j)` /(J WORK PLAN DATED JAIULtaR5_ 2 Zot 3 APPLICATION ACCEPTED BY `I D q Ku, j DA D AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE ��-/j 1 DESTRUCTION INSPECTION BY DATE 17 E COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST/ PR# to $125, ( Opp c01k&v7e4?- / 22-r 3 SR# K3 1 1 RO# 3 375 (3500) PR# (2900 C-57 ✓ WC d _WAIVER _f�_ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT r ENCROACHMENT DOCS EHD 29-01 5/09/12 WELL PERMIT APP