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SAN JOAQUIN COUNTY ORIGINAL ENVIRONMENTAL HEALTH DEPARTMENT LOP N SITE MITIGATION`•._— :7 1868 Hazelton Avenue, Stockton, CA 95205-6232 UN .-�:.:• Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.s' ov.or /ehd WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION 12 2014 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AA``(( Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is mad_e�rl ccY�liBP� Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County E;v�ironmental Health De� �tTISFRVICiES Site Location ��I I N:��j hn- Cross Street Wcka y I nQ� S+ City/State Zip QSL�4 f cAnPN y4; -c)3o-/z Propert vv+,iL Irvi tk e\ Owner Yfl v\ Address 222. IV 1k)iA4Q iA City/State &A64"t- Zip CI L Phone 310 qq6 -3 S(4 C-57 Contractor \otil Addres- (15� kt--)e IZCA City/State M&A'()e?7 Lic S Phone ZJ 31 3"- Consultant/Sub Cntr f� Address 3 1!1 y�1G��n Sl i Su iY-16 City/State t ca .�'"Lic Phone 714-546 (lr Billable Party � 4 vt L[� Address S��Ilr C City/State I` Zip 1�� Phone GIS Coordinates:X 37.93`3`f Y—(2(, 32 (0 CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(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(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) -❑INJECTION(i.e.Air Sparge.Ozones❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑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 W ELL(S)_TO BE DESTROYED PI w—�' OVER-BORE DIAMETER OF INCHES TO DEPTH OF_Z0 FT WELL IDs:tr1iU-I VVIU% 2 w )v1 hi-1-I tti. W.(y VIw' 7 ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATION n,0 Cewie r.(— ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:N 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 a California laws. Signed �/ p Title/Company ! ''/ex✓�al Print Name Date 5A�1� DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS PNV� OQ(C,E , WORK PLAN DATED J 6 IV(As4A a. �.0 1 CI RFf6k-r APPLICATION ACCEPTED BY DATE 1- 1699 GROUT INSPECTION BY FINAL INSPECTION BY DATE 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# $125 x g — 3�e 13 Cs'uN j-12-141 SR# 69(Jg8 2cto 3 375 Ro# 3500 PR# 2900 C-57 WC WAIVER il/(j- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC N EHD 29-01 5/09/12 WELL PERMIT APP