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SAN JOAQUIN COUNTY 5 2 ? ENVIRONMENTAL HEALTH DEPARTMENT LOP �*� I 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION c Telephone: (/ � 1209 468-3454 Fax: (/209 468-3433 Web: www.sigov.org/erhd UNIT IV P l 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 IFI De, ; Cross Street ,) &1kt 5-4, City 5 KU`AJYI Zip �Z APN N5_63_01 Property OwnerAddress �y�Sr G �I City pp L �� Zip�S�y�/ Phone C-57 Contractor i1 �/\ din Address V� City FGN�I (j-'4/�IVN Lic 1/0 Phone 1'1 ` K3 -1101 Consultant/Sub Cntr 4 4tltn1 110WAddresOcity LcCAA L Phone5 6&-&ky(r^ri7 Billable Party v t Address'it C D City &AI I P Zip 1PS l Phone J lv (o3('0- c67— GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER) ❑SOIL BORING IDs WELL IDs 1M1W-N1 OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: QQ\I EXTRACTION.Vapor/Water HAMMER/DRIVEN CASING THICKNESS U TYPE OF CASING: ❑STEEL PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 30 TREMIE TYPE TO BE USED: (AUGERS [HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPEDI Yes No(M IMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i,e Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH �1S` []BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING 0 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) #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,and ap IyFa Ie California Laws. Signed r ( Title/Company it/2it /�d I"9/ - �� 5 ✓!�t/yrt �yc/. Print Name 5 L4kI Date 57-13-12 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,,SIT ADDRESS WORK PLAN DATED �j� c^ APPLICATION ACCEPTED�r 6( .k_4. DATES UED �/_S AREA �1 7 GROUT INSPECTION BY t i L��"� �i FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE L COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST PR# $125 x `oZS �j 7 j t'�) SR#00&71 W RO# J (3500) PR# 2900 C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENTIDOC