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• Aqu(ry. /> •E�_ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LO P 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION ��•rF'-•RN`P Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.siaov.oro/ehUNIT IV WELL & BORING PERMIT APPLICATION z. FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDI •^ ` ATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �Et� q p '' Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in comp)ante with Joaquin County Development Title Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Depamry San Property Site tion l /�� ,tl/y IJ Cross Street _ Ky�{ •'tt�cyl4� City JlC[ r Zip 15-,2&,, � Fy��' t t' Ott 1 Owner if ��. ,nh n '/J �c! Address .Juti (DA ( b �LY1 At11f r.iv.7X p]3g G Phone _ City, Zi C-57 Contractor ��, , Address ''� ;;Vf 5,;, ; v,� City Lic 1y�5,5y Phone Consultant/Sub�jf,nt Address�3 C(�tt1{/+p �( /, 7�UCit WtLao LL/ar ==�,��r/'��r== / - Y J 1 U71` t _ y � Phone�1.7 /16 I4---2Billable Part ti � (=1V Address3�d[itt4'll'fvl��( ��,1$'jjL: CiryPhone �J�s' L GIS Coordinates:X32 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPR013E,HYDROPUNCI-I,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs \, ❑OTHER IDs Q1 TYPE&#OF WELL/BORING INSTALLATION TYPECONSTRUCTION SPECIFICATIONS C —0 MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE ❑MULTIPLE CASINGS C]MULTI-LEVEL WELL CASING DIA' _❑EXTRACTION Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL [3PVC [IOTHER _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED. ❑AUGERS ❑HOSE ❑PIPE —[I SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) 0 _❑INJECTION(i a Air soarae Ozonef❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER ❑OTHER: APPROX BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING❑No E3Yes:Casing Dia: Casing Depth Boring Dia: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS ' r`-TRUCTION WORK TO BE PERFOR D:Mw,w.Ntw_ZI ESTRUCTION METHOD- it (CHECK ALL THAT APPLY( /141 Z V�,-� Vim-I t OVER-BORE DIAMETER of INCHES TO DEPTH OF FT GROUT IDs: _ , MV ��W 2177W'13 1t1-1 N PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIbNs ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO USED:❑AU ERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>§FT) FT BELOW SURFACE COMMENTS l S) t�/I Ute:.. it G n< L-, 111 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 and all applicable California laws. / Signed JWyBi —,— Title/Company (J,co5,5tt dlt;,;e 1{ /h��. Print Name _Swl� I5illi � Oate_j-Z(r II DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 705 �ouN72N el UQ RI-VD -`76e,Crov WORK PLAN DATED 'l q _f+/ APPLICATION ACCEPTED BY O)qK L4 M DATE ISSUED GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK n RECV'D BY DATE I SERVICE RO# INVOICE 35o12.5; •� ' �,�( REQUE.�ScTPR#Z W I2y -``x /1 175"0 Z(o 18�- Qa�r�,E -2°-tl SR#S 'G379 3503 3k, Roo �5�y C-57 WC V WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT �� EHD 29-01 07!26;10 ENCROACHMENT DOC WELL PE ,NIT v.P