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r�9 t" SAN JO/1QUIN COUNTYa ZI INA z ENVIRONMENTAL HEALTH DEPARTMENI LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 .;J.1 '�� , SITE MITIGATION ' UNIT IV \�`o��Foa;;•� Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sgciov.org/ehd WELL & BORING PERMIT APPLICAMMMENTALHEALTH FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONSGWI �N 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 Development Title,Chapter 9-115.3,and the Standards of the San Joaquin County Environmental Health Department. 7 Site Location j� �� 7 Ae ulj b+u�'Cross StreetT(,(,l �� 2 City/State 4 -0 01,rCf�Zip�S 7-Li Z APN �l'��L C� Property // ''11 /// Owner 5 L,fz, Y�L�z< (La t--C1L j Address J?V D-A 2- Y c6 City/State 5 t.yefs -Zip 7'{ Phone 9 d3 C-57 Contractor U=Cc'D L: r',r d Address V" A4 City/State C7 r�Lic f X Phone 7Y?-3�q- '00r' Consultant/Sub-Gfrtr { .k'o ,�L; Address �U� T;—5i, 5rt 30e S City/State/ag F7;L, Lic ^ u Phone Billable PartyNw_IJ.f./� Address SG4:�� City/State j�cs' Zip Phone Sit s�i t GIS Coordinates:X 42A SC Y 2- • L3 ,gig. ISI 'J7_f .`1L' CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs OWELLIDs 6L-'-- 2z L2,1 ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS S C H y U TYPE OF CASING: ❑STEEL I PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL .3 TYPE TO BE USED: [AUGERS ❑HOSE ❑PIPE ❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes l No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(i.e.Air Soaroe.Ozone)[I HAND AUGER GROUT SPECIFICATIONS I"p"L (�—*',» ❑OTHER: ❑OTHER: APPROX.BORING DEPTH /.S ❑BOLTED TRAFFIC BOX OR Q STOVE PIPE CONDUCTOR CASING P,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 WELLS)TO BE DESTROYED OVER-BORE DIAMETER OF tV _INCHES TO DEPTH OF /-�- FT WELL IDs: !7 (-j-Z Z- ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS c{ L.. F ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE P 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 Regulation"nd all 9,pplicable_ alifWia la laws. Title/CSigned ompany Print Name yl' c`cr'•ti=C L `( C L - v1( Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED UK/C- ZU J APPLICATION ACCEPTED BY !3�- I r9/3 K�r.v✓1 T SSUED -14 I AREA l�� � GROUT INSPECTION BY FINAL INSPECTION F" 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 REQUE//STU PR/# $ 125. SR# (3500) PR# (2900) C-57 _x/ WC ./ WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT (j ENCROACHMENT DOC EHD 29-0 5/09/12 WELL PERMIT APP