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ip • SAN JOAQUIN COUNTYENVIRONMENTAL HEALTH DEPARTMENT LOP SIT MkTIG3JT1b 1868 Hazelton Avenue, Stockton, CA 95205-6232Telephone: (209) 468-3147 Fax: (209)468-3433 Web:www.siaov.oralehd WELL & BORING PERMIT APPLICATION SUN 6 201' FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION FOR WELLS AND BORINGS USED �NT�°LHEPLTN NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED cr�``I,,-clkw' r -t�FS Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made iliCbrhg q�Q\S�tn' a' Joaquin County Development Ttle,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. l 1600 Durham Ferry Rd Cross Street Highway 33 City/State Tracy Zip 95376 APN 255-100-04 Site Location ProperlySheldon Teranishi Address 1600 Durham Ferry Road city/state Tracy Zip 95376 phone 209-635-3596 Owner C-57 Contractor V&W Dr1 Ing Address PO Box 970 City/State Lodi Lic720904 Phone 209-369-9600 Ground Zero 1172 Kansas Ave cit /state Mo destcLic95351 Phone 209-522-4119 Consultant/Sub Cnlr Address City /State Party Sheldon Teranishi Address 1600 Durham Ferry City/State Tracy Zip95376 Phone209-835-3596 GIS Coordinates:X Y CONSTRUCT! N WORK TO BE PERFORMED: Refer to Approved WP dated 5/21/13 �IEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) PP ❑SOIL BORING IDs g)WELL IDs AS- - - ❑OTHER IDs TYPE&#OF WELLJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING :9X) LOW STEM DIA.OF BOREHOLE 8 n ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water [jHAMMERIDRIVEN CASING THICKNESS 1 TYPE OF CASING: ❑STEEL"I.`.fy}rPVC [IOTHER [ISOIL VAPOR PROBE [IMUD ROTARY DEPTH OF GROUT SEAL�'TTREMIE TYPE TO BE USED: 0 AUGERS ❑HOSE PIPE _❑SOIL BORING E]PUSH POINT(GP/CPT) GROUT SEAL PUMPED: NeaYesOemNo entt grout 4% MAXIMUM Rw/approx EE FALL PTH(bentonite 3 ❑INJECTION flm.arS ozone/❑HAND AUGER GROUT SPECIFICATIONS _[I OTHER: ❑OTHER: APPROX.BORING DEPTH 5 t IXBOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING®No❑Yes:Casing Die: Casing Depth:_ Boring Dia: COMMENTS: NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORKTO BE PERFORMED: DESTRUCTION METHOD(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE WELL IDs: GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:[I AUGERS ❑HOSE ❑PIPE E] MUSHROOM CAP AT(>3 FT) COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that ve preparep this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and al Ppp i abl Cal!o is r s Authorized Agent / Ground Zero Signed Title/Company Print Name Ra nold Kab anow Date (7 - 3 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS )6 0 0 Dur-halm a WORK PLAN DATED 21, 201,3 APPLICATION ACCEPTED BY 1, /I DATE ISSUED AREA S GROUT INSPECTION BY V 1 GIW bP7"yt¢�, FI AL INSPECTION BY llI&kl.: �" L Qr7r?t-i DATE G 7-1 3 DESTRUCTION INSPECTION BY DATE COMM ENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RD# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# 350 1 g125x 76-6 . 00 0 /3 SR# 67351 RO# - 3 d D (3500 Z G I PR# (2900) C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT OWELLPERMIT APP EHD 29-01 5/09/12