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► SAN JOAQUIN COUNTY NA ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone:(209)468-3147 Fax:(209) 468-3433 Web:www.sigov.org/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 veloprllen,q,Me,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. SE r0 't hvE _ APN S�Site Location o r,4,e• CrossStreet /'v• Fr�-fl S4, City/State prCt'-� Sd0c� / Property p Pro n Owner C•len PQ✓els WV"-f rvlC. Address /t/7� r,�'t f S� /d City/Stater 6np'rv;1(o Zip 7 r/6/I/ Phone 5/0• `1d 8,6 gvo C-57Contractor V✓A� Address 3 5C Q.ve( R� City/StateR;a yi FM Lic7/ap>9 Phone 7P I/> tt p d Consultant/Sub CntrcTh l ,wft a Q Address�/?g ?,1,k-/ ,4l',40,11 City/State d (h-ic-7-5617-3 Phone Billable Party -1Tv«Cl Cl-T Address �0. 11f e _ City/State QIP ZipQ Phone0_1!e GIS Coordinates:X �2 2L I Q2 Y `(21. 2 S 3 Z CONSTRUCTION WORK TO BE PERFORMED: KNEW WELL/BORING(CPT,GEOPROBF HYDROPUNCH,HAND-AUGER,QTH R) GkSOIL BORING IDs S•L•T•I`l .1 - ❑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 ffAAMMER/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 a Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS ']OTHER: ❑OTHER: APPROX.BORING DEPTH /Y t f- ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: _ ��f�Lf �y)� S.,I 6,rj"10 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: ❑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 this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and Regulations,anall app cable California laws. // Signed Title/Company to-e Sr- (C f 6r, C Print NameC1% 411 W Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS lC, C WORK PLAN DATED M 14 � k ) APPLICATION ACCEPTED BY J, 10alCt't DATE ISSUE/Di _t ==--AREA 1("?9 GROUT INSPECTION BY FINAL INSPECTION BY SATE DESTRUCTION INSPECTION BY DATE COMMENTS✓CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE ?q REQUEST PR# 2�vs $125x ZS JCj2 FL c<<� SR# RO# 3500 PR# 2900 C-57 WC _WAIVERC-57 LETTER OF AUTHORIZATION TO SIGN PERMIT v ENCROACHMENT DOCS_ FHD 29-111 6/12 WE[L PERMIT APP