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� r °A4D�N SAN JOAQUIN FILE COPY COUNTY COU ENVIRONMENTAL HEALTH DEPARTMENT 1868 Hazelton Avenue, Stockton, CA 95205- rte�. AL F 623251FMITIGATI7V� ��' cq�rFo ,c Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:wwws ov.or /eh UNIT�I / ,, WELL & BORING PERMIT APPLICATION SEP 201¢. FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E11�rBl � €tFi j ; ! Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in comp�ance with&4n- - TH Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. SEP t"Ile with Site Location , l �I. �r � �,�` Yha.l.r, ' ' 5� a� �j ross Street �Property . � ( City/State� Zi P a Z`tZAPN_C2 Owner_ N� Address C-57 Contractor City/State c-A Zip ij 1r A L Phone �� re 0� N Address _)2, , F . �T yT. City/State 1 Llk ��i� {� Consultant/SubCntr)o j�"1�`�.y � Address �k Lic t{ ) l Phone ��x:G clIIx�i y r--- sill Jk^��ihv �� 'All _.�!V Lic Phone 'i-L-5- Billable PartAddress City/State Zip Phone GIS Coordinates:X ��'77 Y LLz 1,3�c) 2 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS iFp]MONITORING IX HOLLOW STEM DIA.OF BOREHOLE V t% `t G 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: [I AUGERS [I HOSE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes _❑INJECTION(i a Air Soarae Ozone)[IHAND AUGER El No(MAXIMUM FREE FALL DEPTH IS 30 FT) GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH_J(; ❑BOLTED TRAFFIC BOX OR [I STOVE PIPE COMMENTS: CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: #OF WELLS)TO BE DESTROYED DESTRUCTION METHOD:(CHECK ALL THAT APPLY) WELL IDs: ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT GROUT SPECIFICATIONS ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑ PIPE ❑EXPLOSIVES FROM TO FT BELOW SURFACE COMMENTS ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE 5 WORKI% YS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I herebycertify that'I heprepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations ar dd all plicabl ornia laws. Signed / / Title/Company Print Name �� U Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 7`J / /u, TlfdR /v RQ�� WORK PLAN DATED �(5/ APPLICATION ACCEPTED BY J • ,/d lj K"V"I DATE I E�A,�-�—G�' GROUT INSPECTION BY FINAL INSPECTION BY ,�iNw' G DESTRUCTION INSPECTION BY DATE �� :tom/Z4 COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# REQUEST PR# INVOICE Zo C-Ut'7- � C(-Z�('lW SR# 7v�9z 2�O 3�0 RO# 3500 PR# (2900) EHD C-5729-0/24/14 WC — WAIVER P/ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT !/ ENCROACHMENT DOC WELL PERMIT APP