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,o.Pq`•''c\ SAN JOAQUIN COUNTY ORIGINAL ENVIRONMENTAL HEALTH DEPARTMENT 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sogov.org/ehd a"tea ms WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REME NMENTALHEALTH MIT/SERVICES 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�v4op(,E!Nitle,Chapter 9-11 3,and the Standards of the San Joaquin County Environmental Health Department. d ''77 C�'0R�e�s' FWD cc�w r Site Location (/nom�la�f LTt.� Cross Street Cace.1 1461 o,, 1[6- City/State T/'c" Zip 4 5737 APN Z-3-/do- ZZ Property Owner i a Address ?� � v i (o/�' I.Gity/State = Zip 9X Phone Z.d�-$ '�L C•57 Contractor V -Pat\VJr;r: . Address 306 L.J-Creck Ar, City/State S on Lic 72oJ04 Phone 204- 'i69-2 Consultant/Sub Cntr K IQ in�-C��cI Address 30'7-2 f� Cif 'f City/State 9-e r► Lic Phone X07 Billable Party V6frA"(Sw Address J6 T? F;Fc cr'- City/State Zip 9re2) Phone ;aj _IV( GIS Coordinates:X 3 7,t U 2-( Y /Z(.y 6Z/ CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) SOIL BORING IDs 6 - I i D- Z1, 8-3 ^y'• WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Q it _❑ MONITORING JKHOLLOW STEM DIA.OF BOREHOLE O ❑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 N PIPE f [XSOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:( Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(i.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS A10�,`— I0 co 7 ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 12.0 / ❑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 ❑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 hi application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and all applic 'Calif r a laws. 61((p 31,1(p I-7 O li Signed Title/Companys-�— Print Name r Date i 1 [�pDEPARTMENT USE ONLY I SITE MAP IN UNIT IV FILE-SITE ADDRESS I 1 , CLYc2�< 11/04t242 �Tkhfcg WORK PLAN DATED E u3 RL(F}UR I /q C APPLICATION ACCEPTED BY J• Nfk c-t'�( DATE ISS N GROUT INSPECTION BY FINAL INSPECTION BY k-(.-'& 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# o S $ 125 X Y G q� CVCAK t6� </-(`l,/y SR# RO# 2Q0 j 3 7 (3510) -R# (z)00) C-57 (/ WCy WAIVER ✓V k�- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ` ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP