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FILE COPY SAN JOAQUIN COUNTY 2`�..'��I ` z ENVIRONMENTAL HEALTH DEPARTMENT LOP Q: y'.�1i1i "3:'• 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • P Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:www.siaov.ora/ehd UNIT IV 9L/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. ��Z �73 Site Location �SOa N,v i�r,v� Cross Street City S c�tao� Zip`/ :Z0 i APN 162'03-0 Property� I1 pppJ Owner (a?ri.,djiz,T✓icTe, Address City Lt H v Zip Phone C-57 Contractor r!jy� �i vim— Address SU RJ City Lic4` iL Phone Consultant/Sub Cntr ,e 41TG Address 111 L-.,e�,� 5�;)P l�; City I'4,(ns �Lic Phone 2,:h 4�i-222 Billable Party C vo�tiG A--TO Address City Zip Phone GIS Coordinates:X Y 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 _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑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: ❑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 Soaroe.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) __'I_#OF WELL(S)TO BE DESTROYED / OVER-BORE DIAMETER OF S<i„IZ INCHES TO DEPTH OF ZS- SD FT WELL IDs: dW-& 19 C, P I 'z ,� 2P. 107 1 I, PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFI ATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:[DAUGERS [IHOSE F-1PIPEElMUSHROOM 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 prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and all applicable California Laws. (� Signed Title/Company aj L Print Name Date (4,-1�'4- /,I DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS 3 5o E N/4 U QQ(UC- .$7-UC WORK PLAN DATED M P9(ze H 3 0 1 2,01z APPLICATION ACCEPTED BY - y O t� K'✓✓l DATE IS �" '� "1Y 16 GROUT INSPECTION BY FINAL INSPECTION BY TE l 0'1-4 3 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE C/ G REQUEST PR# 02- $125x Ilg,;- CObZ / C�vct /`�7-/3 SR# 06 q RO# 3500 PR# 2900) C-57 j i WC WAIVER_ / C57 LETTER OF AUTHORIZATION TO SIGN PERMIT 1/ ENCROACHMENT DOC !4