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N11 A I P4L'" SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION �'• - :� Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/eh UNIT IV tikokN 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 Gc�,Z 6-. %K-k L70Cross Street 1-(1,6 A City/State Irl CA Zip '?c,'3 APN :25�3 a?-n 03 Property �` // � ff/ Owner �aCct G( S Cl2cF' L Address Cti."C"H RA- City/State j?a—m��ip gY5�S Phone V5'-41(S -6 5Z C-57 Contractor Fau-c"-e Ilcu ti Address 22-N �-5f S+. City/State � �, Lic 96499 Phone Sao-6 1-3�•�) (f Qkk Consultant/Sub Cntr `t c " 9725-yYl-3i37 rcCc^Scr15 Address�)�I lU.��i�t:�t��.K�t�.�rxz City/State G4 LIc Phone Billable Party Address City/State Zip 92165 L= Phone GIS Coordinates:X 'j7 75/8 y2 Y CONSTRUCTION WORK TO BE PERFORMED: / 171 NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) F1 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(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(i a Air Sparge Ozme)❑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) #OF WELL(S)TO BE DESTROYED (g•OVER-BORE DIAMETER OF_INCHES TO DEPTH OF FT WELL IDs: /'•thy I uj aW 1'kc(-1d ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS XJQLkC.,&v,-Q,, ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE O BE U!�ED:pP AUGERS ❑HOSE PIP MUSH OOM CAP AT(>3 FT) FT BLOW SURFACE COMMENTS )ee ci H-a-clt� (f D7--;C7 -�t ��;� C.� (uo:(e(��a j to ( �{' S'o ( 4AS Pro hp C 5 it LIZ�ed. 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 Regulatjpns-,-)sntt all ap Ii blle a iforma laws. (� SignedTitle/Company Print Name tjr-I6( K. 4n(c he s5"" Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 6 ZU Rs;p7' G/R)E 0?04P, TRWL°Y WORK PLAN DATED NV VE•wf Bt2 3 2,t y APPLICATION ACCEPTED BY J• `1orlKct.�i DATE �dPD`.,11? ;=. AREA Mfr �4 GROUT INSPECTION BY FINAL INSPECTION BY w DATE 2- DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE i . +�c REQUEST PR# 2,907— $130. !� !C C'c�lirv7�2_ �('`� SR#CO70977 (3500) PR# 2900 C-57 - WC C/ WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT -ENCROACHMENT DOC _ EHD 29-01 7/24/14 WELL PERMIT APP