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ORIGINAL SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP y.� 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • �;•. - �:P.. Telephone:(209) 468-3147 Fax:(209) 468-3433 Web:www.sigov.org/eh UNIT IV �%FOR 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 Sc?.Z 6-. �r�kf 1%t�i�t�Cross Street lU. lac/�/ u+ City/State Irk Zip '?-:,'3 16 APN �So ?�p3 Property ,/,` // -- ff Owner �� (7�S PIE '�'G Address62-J CiH.RA City/State 9`JS�5> Phone9Z5 y(5-6'52,3 C-57 Contractor Faks�-w"'-' Ilii Address�22-/d.�5t St. City/Statet^-' Lic 94•'6399 Phone L3�•00 Consultant/SubCnttr Yct� SoP15 Address�)2I %�.�� o;K a��. Axa City/State`"SCA Lic Phone cy`i% 3f37 Billable Party 7` {Sc'r<> Address City/State Zip Phone r' GIS Coordinates:X Y 41 5 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 ❑HAMMER/DRIVEN 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(GPI 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 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑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) i(S'+� 15 #OF W ELL(S)TO BE DESTROYED DOVER-BORE DIAMETER OF Jy INCHES TO DEPTH OF 2� FT WELL IDs I�'J, '"l tl''K l J �W-S r u f(r U I ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE U ED:0 AUGERS ❑ HOSE PIPE ❑M SHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS :5,"- "+' ITV d SSC.— %c:t j { .^ we-(( dV-+eG,l 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have pre ared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulati�and all appylica C l' rnia jaws. L Signed Ju�� n r ��/ t �� Title/Company U 0 C'' / Print Name ?14t'x K G C lL2-'0" Date i(! `f I r DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS S 2 b E. TR 04c,y WORK PLAN DATED jyoufrn SER 31 2,0/,4 11 APPLICATION ACCEPTED BY J. yd6jC&4 -I DATIt=I SdJ':8`; ^SSI `AREA 14 GROUT INSPECTION BY FINAL INSPECTION BY 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 REQUEST PR# $130X ►tl O vk,v SR# RO# (3500) PR# 2900) C-57yWC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT !/ ENCROACHMENT DOC EHD 29-01 7/24/14 WELL PERMIT APP