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FIL F ot,a,u!,y c SAN JOAQUIN COUNTY COP y —`Fr ?� ENVIRONMENTAL HEALTH DEPARTMENT 0. LOP •' `• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION �`;•:�;::.�;:P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/eh UNIT IV CrFOR 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 nvironmental Health Department. ` Site Locatiow�� fV�Vy �R Cross Street �Ql \� l}Q CitylState C 1�ip� .�� APN I b3� 10�� OwneProperty k��-C � Address �� 1U. �G`� City/State�,Q �, Zip l56\'_) Phon C-57 Contracl:X){, 1)\)' 'CL V�W? Address�� I �1CC�C.�CV i 1 \1 City/State 0 o C UL ?�` hon 5 Consultant/Sub ` \C//ntrMlYa rTX W tJ Address �� 1 J V-\)CO- �'V E City/StateQ__ C (:CKic~ Phon �� / D0 Billable PartyM\,LC-3JOpW n) Address ft) City/StateC�_nc_-�,Z!p _Phon �37))�(I-J) GI5 Coordinates:X19 U ' 4._7 1 j Y 5?�2 b 1 - I S CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING 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 _❑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 Soarae.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 D STRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CH CK ALL THAT APPLY 1 #OFELL(S TOE DESTROYED ❑OVER-BORE DIAMETER OF It CHES�TO DEPTH OF I O FT WELL IDs:VIAI-� , �� 0 3 � ) q ❑PRESSURE GROUT T DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS El EXPLOSIVESFROM 0 FT BELOW SURFACE TREMIE TYPE TO BE USED: AUGERS ❑ HOSE [:1 PIPE ❑ MUSHROOM CAP AT L3 FT) / C 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 Regula ions nd�ll ap icabl California!aws. Signed Title/Company �2_1c�_m!��" tj`b S� Print Name �U Date S �,,.�yv DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS -S N US Q24�� `57aC'xmo-) WORK PLAN DATED E A?�EP ZO I ( APPLICATION ACCEPTED BY •7c,_� DATE ISSUE �/-Z-1 2 AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE/k44 DESTRUCTION INSPECTION BY DATE -�l-IAij COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST/ PR# $125x uu It�`)2-1z SR# RO# (3500) PR# (2900) -57 WC _WAIVER /I/ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC VjY 'HD 29-01 5/09/12 WELL PERMIT APP