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Pail" SAN JOAQUIN COUNTY �o. �.coG LOP ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION • 600 East Main Street, Stockton, CA 95202-3029 UNIT IV Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sictov.ora/ehd �rFOR 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. Site Location ?SOS A)•".1 Cross Street Tin JJf4-) City S4-v/64V In Zip APN Property]Q Owner l .b.s. Address o2�11/ w �"�1 „ (city S U-fh Zip15�.Ol Phon�yag)�j'�1(e C-57 ContractorT/=G /•/+;+''"'Address 113 f0 A4,s City 70656$ Phone 9J6 -i?S3-�a10 Consultant/Sub Cntr ATC As5otr.4rs_A-C Address 111/ 7 L ow City Lic — Phone Billable Party ATC /4spti&4Ts rrC Address (1/ 7 Lev%t #00— -A-t-4"-city /`t eS-�v Zip 953x1 Phone ��`/-579->>�J GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ®NEW WELL/BORING(CPT,GEQgPRQBE,HYDROPUNCH,HAND-AUGER,OTHER) SOIL BORING IDs SG ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE -l"❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑ EXTRACTION:Vapor/Water ❑ HAMMER/DRIVEN CASING THICKNESS /U A TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER L SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL AJA TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑A No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(i.e.Air Snarae.Ozone)E]HAND AUGER GROUT SPECIFICATIONS N A _❑OTHER: ❑OTHER: APPROX.BORING DEPTH + ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING(4 No❑Yes:Casin Dia: Casing Depth: Boring Dia: COMMENTS: IewA( $ l•sc -0 SL 3'75 )%f31 ?2 r S-" .4�.r1� ;611 L r-1-'-+' 4 47711;7-1. 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 prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulation,/s,/and II plicab a [if is laws. - / L ,/ Signed /(/� ,,JJ J/ JJ Title/Company�r��f/7 U to/Os), //� T� /� ,& 1 A<1 t� Print Name yt TN na+► rd4W ru^ Date b- .2`t- l l _ DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS SSS WORK PLAN DATED APPLICATION ACCEPTED BY DATE ISSUED -2-`f 04Ul AREA997 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: o� d 'S ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE A REQUEST PR# f $122 xL4ll SR# RO# 3500 r^ (2900L�b C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP