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S30I1\83SWIN8.3d U110H1d1N31NNOBIAN3 . c SAN JOAQUIN COUNTY tion I0 o.?`�u tynol G I N A L ENVIRONMENTAL HEALTH DEPARTMENT 03 iN•,� '•) 1868 Hazelton Avenue, Stockton, CA 95205-623 I I ATION Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.siaov.org/eh UNIT IV . catiFgR`'�P 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. 2(c/- ezC—lt Site Location H316 fi, aje IZaJ Cross Street 66LA5 [,,,e- City/State Ripov` Zip U4 APN 2(e1 -040--07 Property Owner Address g3t3 kora City/Stateoti Zip CA Phone C-57 Contractor CcnL,,Ie, Drillrvta Address '31032 OvNee_ G.'r• City/State R�wcho �'FLl!KC ync?1/f) Phone 91(e-G34 -IIri << Consultant/Sub Cntr 6, E. R, Address '351 Ra4 SS RL%,k& City/State 1 o h Lic -C45r— Phone ZaR-999-zo oL! Billable Party &t, I e. Address 3-G1 )LkeS5 ALy.J City/State oh Zip LA Phone GIS Coordinates:X 37 7f; 0-4 1 Y -(2 Ll3'7?_G CONSTRUCTION WORK TO BE PERFORMED: NEW WELLJBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ®WELL IDs E W i7EW - 3 ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ®HOLLOW STEM DIA.OF BOREHOLE I7-" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 3 ® ate EXTRACTION:Vapor/ [IHAMMER/DRIVEN CASING THICKNESS SC1g, kCJ TYPE OF CASING: ❑STEEL tp PVC [I OTHER ❑SOIL VAPOR PROBE El MUD ROTARY DEPTH OF GROUT SEAL -311 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:159 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS /;e<-.4' Ce-cMeKf ❑OTHER: ❑OTHER APPROX.BORING DEPTH C-C o ❑BOLTED TRAFFIC BOX OR ®STOVE PIPE CONDUCTOR CASING I)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 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 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and all applicable California laws. / Signed fVl� %IOia,.vw�Cc�.� Title/Company tJJ�TT 6aftslt Print Name / .,'� �t��t....vv�cp Date -f 2 ad's DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS O ro/i f�y WORK PLAN DATED 00P8e: fS A APPLICATION ACCEPTED BY J• J b/-3'CUwt DATE I39M `' AREA 6 79 GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE 2 REQUEST PR?# $ 1830 x ✓2t dOCA&M �(7.2/-/ SR#�O J 4 o� 10 lJv/�Z (3 500) 2 00 527570 C-57 WC V WAIVER OV C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCR ACHMENT DOC /✓14 EHD 29-01 7/74/14 WELL PERMIT APP