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SAN JOAQUIN COUNTY FILE COPY ENVIRONMENTAL HEALTH DEPARTMENT LOP A I ` SITE MITIGATION 1868 Hazelton Avenue, Stockton, CA 95205-6232 � •. UNIT IV qP/ Telephone: 209 468-3147 Fax: 209 468-3433 Web: 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 Environmental Health Department. Site Location Z L" 7 ti:(v y G ' b Cross$tree T, !1+ C <t', � City/State 5 F� "!� Zip y S C APN /43 -3/ 6 '!6 Property. pp /^� c/; /1 r.^ ( i // Owner TC 11 h G• t)cl('rS,-+1 Address (41"r C L ill ,;r tt, S lr i r ity/State�'�<<�14 h�' Zip C�5-0" Phone S�L 6(6 2i5'5- C-57 1 SC-57 Contractor%R EC""' L C I v f, Address ��5� k L; pl�bt 1= City/State�4r}�q f Z Lic 4 g S!6 s Phone 4�S31"3 5,3C,<' Consultant/Sub Cntr91 S" I �Si�� «'Wdress ISY c PNt �r 1r, St i-ity/StateSu[ LicF ,`4, Phone916 �'.23 5 7C Billable Party Address City/State Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: _ G A� S.4M >r [ � I v El NEW WELL/BORING(CPT,GEOPROBE,HY�ROPUNCH,HAND-AUGER,OTHER) l ®SOILBORINGIDs Gr h" G-��n��r►t'� b vo C' ,- �c 6E'�: CC - �3 tc E �E�, �� 5 ❑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 I7U4 SOIL BORING 9PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(I.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE cr COMMENTS: Zoo CASING❑ o❑Yes:Casing Dia; Casing Depth: Boring Dia: Sc G4S S�•r�1C'� FC �1�5 ) G ti — rT lir— '7 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, nd_all lappliiFabl�California laws. 5k,-',c �.�i ti i<^_ �,b G ZCLCC "r5� Signed Vtn ti'VI 1'" �� '�n/L L-y F C Title/Company)S{( E SCC G k C S 1 t',A;-_; L l Print Name I\ 1 C r PC-X f ,-•I Date l4 nu c i� I Q. 2 z l3 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 2co5 /VAU j d7Rrt WORK PLAN DATED J/341ccdRti 2 za! 3 APPLICATION ACCEPTED BY j DATE ISSUED I-2 y-/ AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE_ DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECWD BY DATE SERVICE RO# INVOICE REQUEST PR# ,ZgOS $125X J 125 cc2?97 (-Z-2-13_ SR# 66W3 RO# 3500) PR# (2900) C-57 WC WAIVER N4:: C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC V i9- _ EHD 29-01 5/09/12 WELL PERMIT APP