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, 411N-:c, SAN JOAQUIN COUNTY � Gli -` ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • -. _ :P/ Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siUov.orgleh UNIT IV 4��FORR� 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�Deevelopment Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department, Site Location 4/ IV�'A• 4� Cross Street lFAC 12/ City/State �EYnAA Zip 9S6 9[;o APN �4/-�(O-D9 Property Owner r,.r Address 5 City/State Zip Phone C-57 Contractor enecON-nr. Address d AJnrT1tx WT ST. City/State UJ.,I�Lic Phone 530 -GCI- 36�0 Consultant/Sub Cntr eS PSoolj Address '4(21 P 61r4n, 61-) City/State�)�Lic Phone q75-9yl-37 3z Billable Party Address City/State Zip Phone GIS Coordinates:X zIy3 1 Y �Fr,2S •� 46W5-- "-f- CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOP OBE,HYDROPUNCH,HA D-AUGER,OTHER) 1 -F( SOIL BORING IDs (�_ �fa.� �- `1 /pZbro so J� WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING 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 A-0 SOIL BORING 1P PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(i.e.Air Soaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS +'.'4t 4"L' Ce—LAA *— ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 204- ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE NX CONDUCTOR CASINGPNo❑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: ElPRESSURE GROUT To DEPTH DF 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 applicatigonn-AadAhat the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and al licable Californi Signed 71 Title/Company L,E,O) ?tnt-Caxe, Print Name -LA0 NVA L-r\ Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE DD7ESS Lam/L"Gl 1 � 7 —77T-/i )7v?WORK PLAN DATED �' APPLICATION ACCEPTED Y DAT AREA p GROUT INSPECTION BY FINAL INSPECTION BY 04X4:%-- DATE 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 REQUEST PR# L ��L'I $ 130 x � Gly _�� SR# "0 RO# (3500 zs 0 G �?� y V C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 7/24/14 WELL PERMIT APP