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o"4�t" SAN JOAQUIN COUNTY �, % R r- _• -r�,-• ENVIRONMENTAL HEALTH DEPARTMENT 1NJA �• 1868 Hazelton Avenue, Stockton, CA 95205-6232 I 1 V ED .P Telephone: (209)468-3147 Fax:(209)468-3433 Web:www.siaov.ora/eh WELL & BORING PERMIT APPLICATION SEP 2 9 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 made in com'p7 h�Sr ES Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location \C5NIXAV1 �J9(-r,oss Street (7A. City/State Zip Z�tL5 ^ APN n5- 130-I& Property r I Owner NM ok v;� Address City/State\a.j /c,A Zip 9T'L4%- Phone C-57 Contractor Q2A t o,,rf_ ress 7-U> N• vW,->T 5rC• City/State Wpm Lic Phone � inl o13id?l`� Consultant/Sub Cntr1%31!jk:As°)T Address ci11 &t ulKo 0-, bK 2 *+City/State 0; Lic Phone q7-5-`14'1-`�uki Billable PartyAddress City/State Zip Phone GIS Coordinates:X 7U��7 7 Y —[2 b 9c(O Z 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 A—%MONITORING Ix HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 2, _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL It PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE APIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH u ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: :OMMENTS: 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 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 WORKIN93rAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify t hp4e prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations, all plicabl ornia laws. Signed Title/Company ( � P�(1Q, t?a(2, \�inU Print Name i\3 J Date "11 Z4'r)1`{ DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS A;, (A kk7bN Roy' WORK PLAN DATED SEP M 2 lc.)i I/ I�r Q APPLICATION ACCEPTED BY J • ✓o19' GROUT INSPECTION BY FINAL INSPECTION BY DATE 04.4 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE p REQUEST P�+R# $130x 20 (,0015 CfdCl(��'E� l C-Zi-/q SR# 76�1?- RO# 3500 PR# 2900 C-57 tl WC ��WAIVER gni I� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT 1/ ENCROACHMENT DOC AlAf EHD 29-01 7/24/14 WELL PERMIT APP