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SAN JOAQUIN COUNTY lk& NAL ENVIRONMENTAL HEALTH DEPARTMEtECER LOP a: a N' '• 1868 Hazelton Avenue, Stockton, CA95205-6232 3UN 0 9 2§1#E MITIGATION Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.ora/ehd UNIT IV WELL & BORING PERMIT APPLICATIQ'IR�®pN�M�Ts� ALc�LTH FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS ANIR'REIVIEDIATION 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 D�evelopmeent�Title, _Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. r Site Location '11 -1 1-v�c1tJ:fidt ttrCross Street aCi City/State Zip 01530'4 APN -ZI Z' X10-IO Propertypp - I 3 q Owner h.� � � ci,,,," Address a 1.i l0 r� City/State 3-616 Zip 9-S7-10 Phone ZY-E3-'f4, TCG- - C-57 Contractor KIV, C� SD MAddress U3o,.;� k CIKceCity/State Lic S Phone 0110 -9573 ' e-0,10 Consultant/Sub CntrEiW+K_0c ,LL. Address .3i35 N. � Yfj CjI,AP City/StateCa4h&d6vFLic Phone711- 2900 Billable Party Ro6a rt f�or,ora.. Address �� k] l�u�f'Rt„t flz, City/State 6n Zip 1�15Z-(O Phone 26'7- 65(o GIS Coordinates:XY 121- ZS" 37.5 7 3_k —12 -1 .1/% k(f CONSTRUCTION WORK TOBF-PERFORMED: EXNEW WELL/BORING(CPT, OPROB YDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2 ►1- ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER — ��J SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE I SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑YepLA No(MAXIMUMI FREE FALL DEPTH IS 30 FT)�.. _E1Ai INJECTION(i.e. rSoaroe.Ozone)ElWHAND AUGER GROUT SPECIFICATIONS y) O,V--1"'j1. "_t- .V tp-,Fv�9t�.�L� ❑OTHER: ❑OTHER: APPROX.BORING DEPTH Zv -QCf ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE ,� `_ CONDUCTOR CASING ElNo❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: _tYn �! S �G k�2 SQ+ - &Ik ho`$o to U-._ {=j=t 52a._w 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 haveprepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations II ap le California laws. Signed Title/Company c"/ D� 1'Y��• Print Name J 1n C)'-N A�� 5 Date /o DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS yZ 7 WORK PLAN DATED .I JU- S /L/ . APPLICATION ACCEPTED BY J 'J D6JAr W1 '( AREA 2 GROUT INSPECTION BY FINAIQid&Z"' -'' t)01¢/C0 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 �] p / �+ REQUESSTp PR# 7�1 v S $125xI 7�4 '�vGt�lP`L�� `e 7-(y SR# ago 3 75" R°o PR# 2900 C-57 WC t/ WAIVER. AZq= C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC 1.14 EHD 29-01 5/09/12 WELL PERMIT APP