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-)14N JUAk�Ully k-UU1V1 r - WhLLrPhXM1:1=AY1'L.pd1 http://www.sjgov.org(ehd/docs/WELIPERA4TF-APPL.r .,oyq coG SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP' y ` SITE MITIGATION 1868 East Hazelton Avenue, Stockton, CA 95205232 NIT IV Telephone: (209)468-3454 Fax:(209) 468-3433 Web:www.sigov.orglehct �) WELL & BORING PERMIT APPLICATION ) FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIQ�I NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'tilAR 15 2013 Application is hereby made to S ntOa_qn County for a permit to construct andlor install the work described This application is add in-•c ,pli nce,w tl)San Joaquin Cou; pW T ,Ohlipter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Depar5152�'t r�' � f%"� `ALf I-i Site Location �y / 'F sf��Cf Cross Street s�/'CC f city /3c'-l>`a zip ifS v AP Z*0y' 01 Z` Property -r- Owner Address PV 130x X07 City �� zip 9 S3G�(Phone�toy��3�Z 7Sa C-57 Contractor V c W Dr;//,in e, Address 3?`a(P �)i ekCfec k bl City 510ckft e% Lic "7 ZO'fO E(Phone(2,09)Y7 S-$c/yG ,•nsultantlSubCntr— P�xv C rivhAddress-�12f1�(�yr� cS-w4•? Cty C�e�-0/->2,i��/—Nc-�ot�s�l Pnenei��$S�-GJ7�f Billable Party Address City zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLJBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER OTHER) ❑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 CASINGTHICKNESS 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 G.e.AkSoaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casirg Dia: Casing Depth: Boring Dia- COMMENTS: NOTE: OFFSITE WELLS & BORINGS-REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALLTHAT APPLY) >!OF WELLS)TO BE DESTROYED El11 DIAMETER OF INCHES TO DEPTH OF FT V CLL IDS: SC f. 7'k W' . / MW ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ScC 7--.6/40 EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED: AUGERS HOSE XPIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW URFA E COMMENTS S'ee G✓crE,0Arv� o4{etc/ Tu/.,I /4 7.,/'L -t;,r o'tsi`rvcr,.� ��PJ�s-r,� 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS I hereby certify that I have pre ed this application d that the Work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations and all a lica alifomi ws. '/ Signed Title/Company ?!o�v �' 14 �1 Ake- Print Name 1"I cf(AEr: UAX-) DEAuENAGU Date 3/0/13 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS S,-I 7p5T-k WORK PLAN DATED t- O/ APPLICATION ACCEPTED BY . yUk9,eU 411 DATE ISSN 7-��' AREA l GROUT INSPECTION BY RNALINSPE 11ONBY /f TE� DESTRUCTION INSPECTION DYp,TE 6 7 /3 CO MM ENTSICO NDITI ON S: �— ACCOUNTING ONLY: _ AID# FAC# PE CODES FEE INF AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE 9 REQUEST PR# SOL $125x �� GIUt:�tiT� 3'/3'f 3 SR# GG 85-,3 3 0 3 3 75 RO# (3500) PR# (2900) C-57 INC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC . of 2 3/6/2013 9:36 AM