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CRIGINA , - ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP Q: 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siQov.oru/eh UNIT IV Cj1=0R 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 E c??g C 6:•^4wf 6k4 el'Cross Street k). M114 A I hu.i Dr. City/StateI r`' u�y �{i�Zip '?5'3 (✓ qpN �25�-)v2?0 03 Property //� __ r/ Owner ��Glt ( (7�S Clt,41 1- Address 16,-'CtiN City/State s zt"K':��ip�Y5�1� Phone9.Zs y/5 --(,5Z5' C-57 Contractor rdtu-Q. 0? 17r I(it I Address�22f'N.ccL5i . City/State011dk114uALic9659v Phone 530-64 3E-cn Consultant/Sub Cnttr rSct7 5 Address-2)2I lU.�d��c;.0 t �.ztI! City/State �I Lic Phone 12'5 `�yf 31c5� Billable Party ?1;,-5 Ott 5 Address City/State Zip 9455 L= Phone GIS Coordinates:X 37• 7y7( 1-y `1Z I, 4114 CONSTRUCTION WORK TO BE PERFORMED: 666 l F]NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) A 1 [:] 4SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION:Vapor!Water ❑HAMMERJDRIVEN 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 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) _#OF WELL(S)TO SE gESTROYED _ II ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: Dl r'—I ��` P t1 �—P PRESSURE GROUT TO DEPTH OF 1,;Z1 FT BELOW SURFACE GROUT SPECIFICATIONS 3,; claw ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE)[Q BE US D:❑A GERS ❑HOSE ❑PIP USH OM CAP AT(>3 Fr) FT BELOW SURFACE COMMENTS � eT',,c C 7TSC -�> �v u c^le P�c� I', e to•- O I P d- l� 77' 177 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 Regulati.oTand all ap Ii a lif ni"ws. / C Signedne-- ) �� Title/Company /41M / Print Name t��I ci 1 K. c llQ 516i-11Date It( `4 I r if DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS S 20 E , (t2N7Ar74j V,n. Ro 7 t R✓�c►`� WORK PLAN DATED b0 V,-Pn I'E 2 3 2,>,cl APPLICATION ACCEPTED BY •JO*Kr:.t OVI DATE.---< Yr ` =AREA �G GROUT INSPECTION BY FINAL INSPECTION BY X D8TE iz`18'�y 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 TTp PR# 2 c�2 $130,, l/ / UZB�79Y �Cx(R/ SR# 7`'1 RO# (3500) PR# 2900 C-57 WC _WAIVER C-57 LETTER pF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 V 4/-14 WELL PERMIT APP