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oAQ,,,H rA ,..- .�a SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP N[ < •' '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 c;•.- :.:.�;:P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sipov.orcllef ��FOR WELL & BORING PERMIT APPLICATION MAY 2 7 2014 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is madFFnRWT/SERV]Mn Joaquin County 741- r „Qr 9-1115.3,and the ISttann�dar of the San Joaquin County Environmental Health Department. .�y cSo S,H9N Sf Kl�Cdd I* ) JJo-orJ Site Location ��.Jla� K....c� Cross Street L/ Shl�i�i ��✓ City/State 7 .tc L Zip APN 2vrf-0Z1.GL Property P/-o 1. S 54, .$Cc Owner Address Pier ory Ba anG City/State 4�� Zip Phone C-57 Contractor C(itt,(e Qi./fig LP Address 3aaQ 01 w A 5�1_ '1City/State Ic 9 1/0 Phone 4/6-90 3--)-73� Consultant/Su Act%W�17 Ad ress t 1�Z �� n Cit /State ��4 Lic Phone 9/6 . SCJ __ LACIBillable Party dress IP .7h 0r� City/State--5 ^"'> Zip 7 6 Phone c -'tom=`!ffib GIS Coordinates:X 3-7. 77 4 Z Y ��(.S/2 Z 3•»Fti Lir, 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.AirSoarae.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 8r BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BEESTROYED OVER-BORE DIAMETER OF INCHES TO DEPTH OF SC7 FT WELL IDs: /`'t.tv- M $V-/cPRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS a at C..-C ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE U ED:❑AUGERS ❑HOSE PIPE / MUSHROOM CAP T(?3 FT) FT FLOW SURFACE COMMENTS �nGwe h t'�(� �,..Ll6r r�rl;JdZ j �✓ /�2V�� C..i(��C .0/Y�^��.rC ci/'y � 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, all applicable California laws. Signed t c Title/Company(.� � P C�nr5h7�a-/�y�cTS v��• �u Print Name Si _,1� --p Date_, l 3—/y / DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS /7'/ST lU S Ey I C nO14I) /), 5C16g?L TE p/kJ( 7 2*?y WORK PLAN DATED / O/41 pRIgg APPLICATION ACCEPTED BY �l-_ 0 1-7 DAT I EAI GROUT INSPECTION BY FINAL INSPECTION BYI-y+.0�,��' r ^�T DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE c REQUEST PR# $125, 3��I oZQ C'(-)U;t J` SR# 3 �OIU 33753 00 PR# 2900 C-57WC // WAIVER X-1 a C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC 01 EHD 29-01 5/09/12 WELL PERMIT APP