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rLjSAN �IOAQUIN COUNTY ORIGINAL. ENVIRONMENTAL HEALTH DEPARTMENT LOP .ti = '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIG N • �Ii=OR��P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.oralehd,C V VWELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATE N ZQ�� U�- 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 com0iiance yo -San .r1it Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Deep .p�grtt�,,�o�, Site Location 7.S-7 F%�1 T 4 5`'L Cross Street ti!M �' � u e- City/State a MZip r 5 O A PN�� Owner b Address7Z� LjYfh AtCity/Stat d'W'/ILIA Ito a 4:_Phone C-57 Contractor e," a Address /� �(Cw'� Citylstate r � K, YtLic $Sr'6 Phone�7 sgr�f3` 'E170 Consultant/Sub 1 Cntr EF -W�• Address/-Z77 7i��' v k City/State0G CA Lie Phone Billable Partyl�l+°kwzj} fr We- Address 35 7 67- 4-V-C City/State?'.M L'Zip/SZ.Z - Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs ❑WELL IQs ❑ OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE. CONSTRUCTION SPECIFICATIONS _❑ MONITORING Cl 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(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH 1S 30 FT) _❑INJECTION li.e.ArSveme 0zone)❑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) 1/ #OF WELL(S)TO BE. DESTROYED / p BZVER-BORE DIAMETER OF_INCHES TO DEPTH OF V41rt Wt FT WELL IDs:/0 a' -I. - I 1 t&1-0L[q k A4 - O ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:KAUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT(}3 FT) FT BELOW SURFACE COMMENTS 6 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 Regulation_`and all applicable CstliforniaAws. _ Signed l�1 �5 _ Title/Company_ G(�d0► ��(-G�GS�, Print Name r,L��4bb2:'t _Date �-tc� +'3 r DEPART ENT USE ONLY SITE MAP IN UN1T,•IV FILE- ITE DRESS 7> 7 • l l 0)"U1 C401C' a o 047 7 j WORK PLAN DATED .. APPLICATION ACCEPTS BY DATE REA GROUT INSPECTION BY FINAL INSPECTION BY ATE '7-14-f DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: / ACCOUNTING ONLY: AID# FAC# ' PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 5 d $125 x bp 1, 000.7 Fry 1-14KI, S11#006707 07 3 �J ! 20 (3oa 27 -PRS 2900 C-57 ✓ WC WAIVER _4Z P, C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC&iq__ . EHD 29-01 5!09112 WELL PERMIT APP 1