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SAN ..IOAQUIN COUNTY OR I G I NA !- x° �o ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone: 209 468-3147 Fax: 209 468-3433 UNIT IV c,Foq P ( ) ( ) Web:www.slgov.orq/eh 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 G(i^n w V Cross Street 1`. t G�ktY�C� %T�Q City/State S��'}< '" zip ISZOO APN �G Property �--_ /1I� Owner Cit{ Y Sic k k,� Address X125 N• G� w, e� S�City/State Ca t>an Zip Ot`'Zd7— Phone(?-q)'43-+ C-57 Contractor CP(SC6t&Q- Dri(LYYVtkddress 3000 Dxj j)TA,S1r- City/State W- SAC M I. Phone O�— Consultant/Sub Cntr LA J✓Address *� City/State - �Lic Phone - 15 Billable Part �t( -'IVA- `I Address k City/State H Zip Phone " v GIS Coordinates.X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑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 _❑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(re.Nr sparge Ozones❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING ElNo❑Yes:Casing Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHEcw ai• -HAT APPLY) �p #OF WELL(S) BE DESTROYED OVER-BORE DIAMETER OF_ '$ _INCHES TO DEPTH OF FT WELL IDs: S - S-(0 S-IS ❑PRESSURE GROUT TO DEPTH OF FT BELOW SAJRFACE GROUT SPECIFICATIONS - 5g1jonS R20 12C/ ,j Ib. rn ] ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO§E USED: UGE S HOSE PIP€ _^ t ❑12 /Y MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS ESS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 1 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, rolcable.California laws. Signed Title/Company 0 yr Grzl— Print Name 9P-1 DCrL-T F-1-0-ilD F-1-0yLj Date (Z IZ ZU jLj DEPARTMENT nUSE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 12-6-) ! +bUAlIT/12Y `9V 1� WORK PLAN DATED f f U7Y APPLICATION ACCEPTED BY J. Yo(AKKM DATE Ian A /G4�i GROUT INSPECTION BY FINAL INSPECTION BY - -1� ip- DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE �q� REQUEST PR# .3SUZ $ 130x �j20 © 3C� ��1w 1('LSR# ?It 350 3% RO# (3500 PR# 2900) C-57 L," WC WAIVER C-57 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 7/24/14 WELL PERMIT APP