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SAN .IOAQUIN COUNTY; ENVIRONMENTAL HEALTH DEPARTMENT LOP ? 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION •=...,- = :� :• Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.siaov.ora/eh UNIT IV 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 Hyo F• 4a.rrrI «f' L„ Cross Street wC5} Lot^e, City/State'Vwc.k�^ Zip g57Dq APN Propertyu��o� �* � ^ // Address 2!57'7 +w, go-Mort CitylState � a^ e+Zip' q(150 Phone q25— ��/S'83e;y C-57Contractor &-& �r/<�<�� Address 9se- lC D Hove- City/Slate/411--l"Ot'L Lic � S I AS Phone 032- 513-58,00 Consultant/SubCntr Ade., C9 ' Address //bSO Wh:;- Rock R) .` City/StateAJ1-'tckD Lic Phone 9rlb`SD��/277 Billable Party A Je. &r A p Address SH i A //D City/State&40-- Zip X1567 p Phone 1 „ 0 1 u Coordinates:X 31'01 11.61 IJ Y 121 /7 `/3.S6 cJ CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,0THER) ❑SOIL BORING IDs ❑WELL IDS ❑OTHER IDs TYPE&#OF WE INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS `❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS 'TYPE OF CASING: ❑STEEL ❑PVC []'OTHER I _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL =TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:El Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Sipa ae.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) _?__#OF WELL(S)TO BE, DESTROYED - ❑OVER-BORE DIAMETER OF INCHFS_TO DEPTH OF FT WELL IDs: M'✓'6, A^) .1,1W- 7 PRESSURE GROUT TO DEPTH OF- 60 FT BELOW SURFACE GROUT SPECIFICATIONS A, "'_'' ❑.EXPLOSIVES FROM 'TO FT BELOW SURFACE t TREMIE TYPE TO BE USED:❑AUGERS S1 HOSE [_1PIPE P?MUSHROOM CAP AT L3 FT) 2 FT BELOW SURFACE :COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 1 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,an I app�lic�ble�California laws. G I Signed _ /�' Title/Company. Pr' ,%._-J Pro+-cSSi.�a�1144ew ,one. I Print Name EJe—K r-s1 T. GJe r-q�+f Date S 1o�J'z ) D PARTMENT USE ONLY` y' SITE MAP IN UNIT IV FI S! E ADDRESS f�d�� O� top 5-4 Cmc.•11Z6 WORK PLAN DATED J Z APPLICATION ACCEPTED DATE ISSUED /2- AREA GROUT INSPECTION BY FINAL INSPECT19N BY DATE DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: p ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO- AMT REMIT TEp CHECK# RECV'D BY PATE SERVICE RO#: INVOICE REQUEST PR# Oz $ 125 x Z Z'Sb . S7 34if $Zl SR# Gs 0 31 e• .. e 4 RO iL (3500). PIR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT.DOC EHD 29-01 5/09!12 WELL PERMIT APP g