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SAN JOA UIN COUNTY ORIGINAL r ENVIRONMENTAL HEALTH DEPARTMENT LOP 11868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION ��..:;••;::.N:P Telephone:(209) 468-3147 Fax:(209) 468-3433 Web: ==^y'� _w.grrglEl:._ UNIT IV <t pOR 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 Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location Cross Street City/State d Zlp �� APN /u9 nit'• '1 Property Owner t Address � City/State Phone C-57 Contractor V `�`10 V(&t- % A'ddress �' J�, Gf2r=`Ic City/State '=� '"�1ic 1' �"�L Phone X05 �/� 7�� Consultant/Sub Cntr address 55(1i' l�/r'i=r'<Z�`T T-OCity/State <m~.. 485 Phone Sac- �+7�- S"5 S Billable Party U126IZ / »/i Address '5,4� W City/State Zip Phone GIS Coordinates:X %�•�'f_ Y /'y.Z o 37• -c;Nrti —121. 280/9' CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH•HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN 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:Cl Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION a .Air So me.Oz« )❑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: AVE4T C�`/'>�Nl GRotc? �7o�6ttToy[?L NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY #OF WE ) 0 B nF$ OY� 0 OVER-BORE DIAMETER OF CHES TO DEPTH OF ��FT WELL IDs: '� �A1-/2 V�$0/ [29 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS L❑j HOSE ❑PIPE ❑ U M CAP AT(>3 FT) FT BELOW,SURFACE COMMENTS V I ►� VM$ F1F453kj(6ewwaT- loom MtcSHayo/" per— /�.tJ.C7hrFR5 IJ.x�D�1!��b5 � 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have pr pared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and all appll al is laws. _ Signed Title/Company CFO Print Name Date 2. i y ©© DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS Q� n'1 191/v ST�r 50 � WORK PLAN DATED APPLICATION ACCEPTED BY H'f DATE REA /G GROUT INSPECTION BY FINAL INSPECTION BY ATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV D BY DATE SERVICE RO#REQUEST I PR INVOICE $125. / t'3 75 \ _ Q�Cciv7b(Z SR# b 18 RO# ZC(C7 3%s 37S (3500 l PR# 2900 C-57 WC /WAIVER—pV C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC EHD 29-01 5109/12 WELL PERMIT AP