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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP e: -t '• 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 s�Z E• G'4wT�i K L��Cross Street tU_ t AAA11-i" D City/State I+ 4r'.��i Zip q� 5 fL APN �o 03 Property� � // rr �— Owner �/t,L{ya54C�2� '� Address3`i1CY JCk,N.fid- City/State;0 "^zn.c:6ipqYSa:> Phone9Zs yrs C-57 Contractor P. �Illi"; Address 22F,N uL5f St. City/State"42kz J,4�Lic 9 g`l9 Phone S3v-6k I 3E•cC) 5 a (�� {c; � � City/State` LiC Phone Consultant/SubCntr 0.'.'S�ri Address-21-21 < <� �'� 9�5 `1`+l-3i�37 Billable Party P"'-scn 5 Address City/State Zip Phone GIS Coordinates:X 3 7.7447 Y 'YZ f.44141 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) h�/J/) ❑SOIL BORING IDs /V A ❑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:Vaporl 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 Ozone)[IHAND 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 W ELLS)TO B DESTRPYEDOVER-BORE DIAMETER OF %y INCHES TO DEPTH OF (3 FT WELL IDs: 1 - / r,-t•t— �� ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:(GAUGERS ❑HOSE PIPE ❑ TSHROOM Cqp A (?3 FT) FT BELOW SURFACE COMMENTS 5¢� 4' c�tllXC PTS6-ct,�ofr7��c work�l��vi �{ 7�a��E I 4r; ivZll d�:f<tiilS �' C E1tLo 5 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 Regulatiand all app icab rnia laws. Yv Signed 9 '� Title/Company PrintName �� K �� X12 Sc•l Date I t r I l DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS Jt 20 E, 61?9rv7A11VF Rona, TR19C7 V WORK PLAN DATED D UFn'r 15,20 APPLICATION ACCEPTED BY J Y061Cur.•t DATE ISSIJ `' ' , y 4 /(a GROUT INSPECTION BY FINAL INSPECTION BY_ QPOsrog1 DATE /2-/8-/'1 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: - kACCOUNTINjGONLY: AID# FAC#FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE 1QREQUEST PR#$130. (0 UZg s.� /4 (20CIIi�/L ��/z./ SR# 70977 RO# (3500) PR# (2900 C-57_(, WC 1.-' WAIVER C-57 LETTER pF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC /v EHD 29-01 7/24/14 WELL PERMI APP