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SAN JOAQUIN COUNTY V R I V NL ENVIRONMENTAL HEALTH DEPARTMENT y: 1868 Hazelton Avenue, Stockton, CA 95205-6232 REi UNIT IV ® •. :Pi Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sogov.org/ehd MAY 2 7 2014 4�/FORa WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIONMENTAL HEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES 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 Count 7ter 9-1115.3,and he Standard of�v � S th San Joaquin County Environmental Health Department. Site Location(p R4.. Cross treet�. S�Cr.��-c.C.( City/State ^/•.c L.FZip APN 9n9 -VZZ-O4 Property F('-09R f i -c4 c S �`, %r- (•.�p�� Owner G_ ,..1 �..�.�L..Q StN�Gcs Address loco r�EO�I� D�"� City/StateM�O"ru`�S Zips $l0 Phone d1/2-L6Z-937,T" C-57 Contractor C�soL�D�%ll.. L•#o Address 30`� �- City/State�' �Lic qq;; �� Phone q14 � i3T6�T�� e � c. a 1 ST7 Consultant/Sub Cntr �F�ddreSS , 15..tt�o� City/State Gric Phone C1 t!L-r�'F9- qts GR.4 "0 o� �. Ses Billable Party A Zr L.,fi ddress /9�S'►'9 Q,-�s/.�c 0' "�3z ity/State ,Sd^o^��Zip_"I - 76 Phone -7 o-7-y,3r `1'?S GIS Coordinates:X 37•Z��3 Y -f 2(,{c28q 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.AirSoarge.Ozone)❑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: ,h60'l DESTRUCTION METHOD: CHECK ALL THAT APPLY I°•s,'tS Z #OF WELL(SLTO BE DESTROYEC H4i�Z�MV�Jr��t4.-�(�/fit li��✓.�i {&OVER-BORE DIAMETER OF INCHES TO DEPTH OFf-SO FT WELL IDs: N'4 Cllr-"7 /ri..Y 14t,-7,J�ta�a�h�,.�llAlwgLM649( t PRESSURE GROUT TO DEPTH FT BELOW SURFACE GROUT SPECIFICATIONS rk� A/e �V-1, V I+N2. []EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:JRAU��jjER,Y ❑�HOSE j��Q PIPE L;-3 �M USHROOM CAP AT(?3 FT) FT BELOW SURFACE COMMENTS I„ !I'7 c.�lt Sc �� ` vA weds w.ll be i4 rk-^1 t.A l ff 3 4-1 Gcsi + Gw. L.s 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 all appiicab California laws. / I Signed Title/Company e"— I r (o-.&.s O'ss 4 .ea-r:J it A-,aS Print Name Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS HnfV 1U N.O� S Kuc.T E 9r WORK PLAN DATED ✓} U APPLICATION ACCEPTED BY J• `1 U q K u ,A DATE AREA co GROUT INSPECTION BY FINAL INSPECTION BY � _----RATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUESTp PR#L/ ),902- $125 x 20 2 ct 3 ?q c z0 Cou#vm 5-26- SR# PR# 2900 C-57 (/ WC [i WAIVER /L1/t C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOCS EHD 29-01 5/09/12 WELL PERMIT APP