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SAN JOAQUIN COUNTY ORIGINAL ENVIRONMENTAL HEALTH DEPARTMENT LOP N' �c �==1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION �q r E Tea e:(209) 468-3147 Fax: (209) 468-3433 Web:www.s*gov.orgleh UNIT IV ��FOR S�FFr Q �� WELL & BORING PERMIT APPLICATION FQR VIIELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION ENVIRONMENTALNON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is herebyr ��ql FJpag0n County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Developmen tle, hapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. '�11 1�Z- t3 Site Location jq& JV I�vnkr ��f� tCross Street IV'-L S F City/State` Zip gS �UZ APN 1 3 1-13 Gn=> Property .)-73 oon+r (Ajb, 5to k+c^ Owner Mr,)td'S cyV Address City/State C P, Zip `l'D, �`1 Phone�cli- `I( l^ --f393 '.-tom Gr1 � C-57 ContractorvcL,.% Address&,cL;,b,`K Crcel 1)r City/State, C-kA Lic 7-Zo Phone `i y4:, -7700 �fv,Fz ConsultanVSub Cntr T� Address !c5 rv1v:r,5 s<iJ(�v- City/State �`I' "' Lic �3 Phone jC7-��(-l L 9u Billable Party l oc,,iFzEnu,rc:,v tfrWAddress >IL ITie City/State Z.'(-14 Zip Phone-Iy7-2'-;1q-At- GIS Coordinates:X 7 cISSNS Y '/� l. Lo CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CP GEOPROBE HYDROPUNCH,HAND-AUGER,OTHER) ® SOIL BORING IDs B i+ a, 3 3 . 3 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE Lj— ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water 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 e Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ko 1�b ❑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 ❑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 epared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, nd all applic le California law _ Signe — Title/Company ✓� -e5s (r Print Name U r V I 7 Date (D^ I'- IV DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 1.�ly N. 1f4N7-6R 5V&-7-- 57EVk1U) WORK PLAN DATED /L / 2-U/q e- r APPLICATION ACCEPTED BY It.Y oro-c cf2, DATE AREA �6 GROUT INSPECTION BY FINAL INSPECTION BY UATE 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# 2C(O $130. 26 1322- 6.4rv7E& 12-1-IC-1 SR# 7107!.0 n G RO# /�C(O 3 IO �p 5 (3500) ( ) 7/v7 C-57 1, WC V WAIVER tV Y)- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC Ale EHD 29-01 7/24/14 WELL PERMIT APP