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I ! SAN JOAQUIN COUNTY ° t ro - ��` ENVIRONMENTAL HEALTH DEPARTMENT LOP w � - SITE MITIGATION 202 .�•.. �. 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209)'468-3454 Fax: (209) 468-3433 Web:www.sigov.org/eh WELL:& BORING PERMIT APPLICATION.. FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED T Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described. This application is ma 1rV T Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. � ` {{{ site Location ss streetY .I�t — _ 1. City Tir c L zip `�5 3 APN Property Q �� 5 (�'`�) 3 3-3yk 110.r3yi�• o� 5 7 GJ. G r } i..r j. 3 Phone Owner Address. � City �- � Zip C-57 Contractor t AddresL �+ G� � P � ! �.2 n Address 5 ��g lG �t sib Z�� Cit l7a�rl'1�� Lic q 7�'CD Phone Consultant/Sub Cntr S _ y B 11 table Party Ly, Sc,,Li- Ln5 _.- Address Z-'Z'O City Zip JySZ{. Phone GIs Coordinates:X t'Zl`zl,�1'7-f Y-3715."3-59 CONSTRUCTION WORK TO BE PERFORMED: I ❑NEW WELLIBORINGi(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER) ❑SOIL BORING IDS []WELL IDs ❑OTHER IDs TYPE&#OF WELLJBORING 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 I: _❑SOIL BORING ❑PUSH POINT(GP!CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION f(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 Dla: COMMENTS: . NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS ' DESTRUCTION WORK TO BE PERFORMED:, DESTRUCTION METHOD: CHECK ALL THAT APPLY) 5— _k-0 #OF WELL(S)TO BE DESTROYED CROVER-BORE DIAMETER OF YJ0 3 INCHES TO DEPTH OF FT WELL IDs:olt,.?-!fc �- 05-1 1•c J0 CW-I e4 V V 1 .v - ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:I]AUGERS I]HOPE [KPIPE MUSHROOM CPIP AT(>3,FT) FT BELOW SURFACE COMMENTS It r,l l5 w.l I i& elf:i f—I 'il c.- i..•.•� ;.i r�1, "cc,��a M �F-� c��-c..�s r z" P,F G .� 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,a all pplicable C I.Qrnia laws. I Signed a —Title/Company' Print Name he - Date _- DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-�J TE DDRESS WORK PLAN DATED ©/S 4 APPLICATION ACCEPTED BY DATE ISSUED AREA 9G GROUT INSPECTION BY FINAL INSPEfTION BY DATE DESTRUCTION INSPECTION BY AXILi tJl�� DATE D / COMMENTS/CONDITIONS: 7 ACCOUNTING ONLY: AID# FAG# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY 'DATE SERVICE RO# INVOICE REQUEST PR# ci` -C7 $ 122x ZU )-5 Q" SR# UU�3bly oa 1110#060cSN17 OV27 2t`�SJr [r 350f? PR# (2900). :- C-57' 940. .- C-57' WCWAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC J EHD 29-01 07128110 WELL PERMIT APP I