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0RIG ► I A L op41'" SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP y 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION a:�%, Telephone: (209)468-3147 Fax:(209) 468-3433 Web:www.sigov.org/ehd UNIT IV \lF0 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. IS-3,4,71 G,i e� Site Location 1/0-1 eW Cross Street Ypn I City/State Zip I q S37,0 APN j/- 01 Property I 600AVBn Ft f1 ' L .IZA p 9 6� 3i h 1- 3-'03 Owner �Ct U�r r:ok. ��C Address C-lc,r;, 4i..? r� - City/State /� Zi b0 Phone J I O- 0 C-57 Contractor or f Address- 0 6:1<Creelt. Dr. City/State r C .ur, Lic '20 I{ Phone it)9- '469 -72,01D Consultant/SubCntr 5N67cb Address S-RO Ill. W:IMn. I.DeA City/Stale R,Pc!% Lic dA Phone 20r-?21-Z66-.f-- Billable Party C �� (S1 Address i City/State Zip Phone GIS Coordinates:X 37.'C3Z 3 2 Y `f L I•X9K CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑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 _❑SOIL BORING ❑PUSH POINT(G P/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION Re.Nr Sparge.Ozonel❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dix COMMENTS: NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF W ELLS)TO BE DESTROYED ,RrOVER-BORE DIAMETER OF P INCHES TO DEPTH OF FT WELL IDs: W- '- ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS A/e". 0/112n ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE fB PIPE ❑MUSHROOM CAP AT(>3 FT) Fr BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that have prepare this ap,Ptication and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,an 1��plica/ble al•fori ' Signed W� Title/Company �nV+f�f 448 1 k I —CQ-A/•!1 Print Name Date Ll DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 72/ 5;019kj 192 ELI it)6! WORK PLAN DATED Mq I 7 r' &I-L� APPLICATION ACCEPTED BY l `�O4Kxr r) DATE ` ` AREA GROUT INSPECTION BY FINAL INSPECTION BY `�'yDi�/Cu�., _ DATE DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# $125. C) L,7- SR# RO# 3500 PR# 2900 C-57 I/ WC WAIVER (V✓�- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ),ENCROACHMENT DOC�� EHD T9:61 5 009/12 WELL PERMIT APP