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FILE COPY SAN JOAQUIN COUNTY Q: �`r Z ENVIRONMENTAL HEALTH DEPARTMENT LOP W SITE MITIGATION • 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3454 Fax.' (209) 468-3433 Web:www.siaov.org/ehd UNIT IV 4�%ppR� 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 D@v o tCitle,Chapter 9-1115.3,and the Standfards of the San)Joaquin County Environmental Health Department. /&Zp3p p7 Site LocationS7 V•? 'Nq-vt Cross Street City 5�ar -, Zip Property Owner lo't�� 7ZcK{y^ Address Zt7� ('�z:� l),,�;y;�r �� City 54! rfc- Zip'3SLc 3 Phone 2cc1-j1��~G'�f� C-57 Contractor v ,> Address 1;50 46 L,),(2 City 1�1,.-1"r Z. Lic 4 P316 7 Phone'72 51V'00 Consultant/Sub Cntr L-rJ�r, 4TH Address111 , ,�{7 , t la 5�"?,')l City Lic Phone 704-%---;L9-22?I Billable Party ':�-4 471-6, 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 Soarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE 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) _L0 #OF WELL(S)TO BE DESTROYED daOVER-BORE DIAMETER OF k1,112 INCHES TO DEPTH OF V.,vie 5 FT WELL IDS: ilw-IS 16, (-;L i t !$ 2z c � 11P-15 1 G l- M+„-i S, ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS f• ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: AUGERS ❑HOSE ❑ PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS k�-, i-oy 4, :E 1-r C"'L, 'nA V 1 -v!h 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 1 hereby certify that 1 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. — Title/Company Signed Print Name Date I-7-i3 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS 3 s(DS N&y N 2 I UE S Tcex-oG -) WORK PLAN DATED ( C) Z,O 1 Z APPLICATION ACCEPTED BYJ• Y r?/�tGt t ��l DATE IS ZRA GROUT INSPECTION BY FINAL INSPECTION BY DATE l LY DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID* FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE C; A REQUEST PR# (C� 2 $125x 10 1Zb� ) Jar O 2- C,°Ctl 7�-Q SR# 05 072 2 C� -2RO# `0 / �7 5 37 3500 PR# (z9oo) C-57 WC // WAIVER (V n— C57 LETTER OF AUTHORIZATION TO SIGN PERMIT /ENCROACHMENT DOC__&j�__