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i ORIGINAL Ik 5b� 6)�,S 'V&045.s SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP a; • 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.sigov.orq/ehd UNIT IV 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 W.l I�CY' iCross Street L (�� r� City(Slale' fzip APN Property 1 l ti(�.e C,- Owner C 1) Address - 1 t City/State (fZlpbpi b Phone��)Lf C-57 Contractor la�-rep 7 0n11� Address Cil/Slate tt �� )LIC Phoneg,3Q53;3 -S-9z) Consultant/SubCntr Address 1 ��Cfly75Ta�e i �� Li�� L�dl�UPhoneirLl7 .��j�G�S21S Billable Party Address t, I r City/State Zip 1f'7 Phonet/05 A -3 GIS Coordinates:X 37. 9y � (3 Y "/4( 300( ' CO STRUCTION WORK TO BE PER NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ['OTHER IDs 4;,Ij I c - E -`t g TYPE&#OF WELL/BORING INSTALLA4"TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑-KX4Caw S+s+• DIA.OF BOREHOLE tU� ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 'l _[I EXTRACTION:Vapor/Water C] CASING THICKNESS , TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER 11 OIL VAPOR PROBE 0 WA.ocuI o• DEPTH OF GROUT SEAL IL21 bEr` 5 TREMIE TYPE TO BE USED: AUGERS ❑HOSE ❑PIPE ❑SOIL BORING ❑VUS&4 l*M+'(GP/CPT) GROUT SEAL PUMPED:❑Yes • No(MAXIMUM FREE FALL DEPTH IS 30 FT) it _❑INJECTION(i.e.Air Soarae.Ozone/ HAND ukA i b�GROUT SPECIFICATIONS b4f X11*YI/l( _❑OTHER: OTHER: 7 APsPROX.BORING DEPTH t V ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE r 1n t� 1/1 k) --5 CO DUCTOR CASING�No❑Yes:Casing Dla: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS & BO*XNGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORIIIII r DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELLS)TO BE DESTROYL. ❑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:❑Ati(3ER5 ►s PIPE ❑MUSHROOM CAP Ar(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REWIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this apptsc.w-x+and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all licable Cal-forma lash Signed '� Title/Company Print Name A 2 Date7�/'/ L, DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS OO W I NU��If STiCEE r� Sr WORK PLAN DATED ©e t-,, Cz Q 29, 2,01 APPLICATION ACCEPTED BY J• m i%K" DATE I " - EA �L49 GROUT INSPECTION BY FINAL INSPECTION BY C TE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 2`C OS $125X / ECE'L7 2-7-(q SR# 50C1 OC RO# 3500 PR# 2900 C-57 WC (,' WAIVER n- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _'ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT PP